Registration

Sea Salt Fundraiser
Thursday, March 7, 2024 | 5:00PM - 7:00PM
1186 3rd St S, Naples, FL 34102
$50 Per Person

Event:

Start Date/Time:

End Date/Time:

Fee per Family:

Room:

* - denotes required fields

Family Information

	First Name:*	Last Name: *
	Type
	Home Phone:*	Cell #: Work #:
	Email:*	(Emails are kept confidential)

	Address: *
	City: *	State: * Zip: *
	Emergency Contact Info (Not Contact #1 or #2)

Add New Student #1:

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	Student's First Name: *	Last Name: *
	Student Gender: *	Birth Date: * (format=mm/dd/yyyy)
	Student Email:
	School:	Grade Level:
	Disabilities (Leave blank if NONE):
	Allergies (Leave blank if NONE):
	Medications (Leave blank if NONE):
	Primary Doctor:
	Student Birth Year:*
	Previous Soccer Club:*
	Position:*
	Ready to join now or next year:*
	Shirt/Short Size (CXS - AL):

Add New Student #2:

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Add New Student #3:

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Add New Student #4:

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Add New Student #5:

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Questions/Options:


How many people are you registering and what are the names? *

Additional Information:

Other Questions/Comments:

Credit Card Verification:

Card Number: *

Name as it appears on card: *

Nickname:

Card Expiration Month: *

Exp Year: *

Address Line 1:

Address Line 2:

City:

State: Zip:*

eCheck/Bank Draft:

Bank Name:

Bank Routing Number:

(9-digit number)

Your Account Name:

(Your name on your bank statement)

Your Account Type:

Account Number: