Evergreen Junior Academy

Evergreen Junior Academy

Fall 2016 Registration
Parent #1 Name *

Prefix First Name Last Name
Parent #2 Name

Prefix First Name Last Name
Parent #1 Phone *

Area Code Phone Number
Parent #2 Phone

Area Code Phone Number
E-mail #1 *
E-mail #2 *

Address #1 *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Address 2

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Registrant #1 Information
Player

First Name Last Name
Birth Date

Month Day Year
Gender
Phone Number

Area Code Phone Number
E-mail
Name of School
Emergency Contact
Other than Parent/Guardian above
Emergency Contact #

Area Code Phone Number
Care Card
Family Doctor
Allergies or Medical Issues
Other
Membership Category
One lump sum payment due upon registration
Training Group
10 Equal Monthly Payments via pre-authorized debit only.
2nd or 3rd Training Day
Registrant # 2
Name

First Name Last Name
Birth Date

Month Day Year
Gender
Phone Number

Area Code Phone Number
E-mail
Name of School
Emergency Contact
Other than Parent/Guardian above
Emergency Contact #

Area Code Phone Number
Care Card
Family Doctor
Allergies or Medical Issues
Other
Membership Category
One lump sum payment due upon registration
Training Group
10 Equal Monthly Payments via pre-authorized debit only.
2nd or 3rd Training Day
Registrant # 3
Name

First Name Last Name
Birth Date

Month Day Year
Gender
Phone Number

Area Code Phone Number
E-mail
Name of School
Emergency Contact
Other than Parent/Guardian above
Emergency Contact #

Area Code Phone Number
Care Card
Family Doctor
Allergies or Medical Issues
Other
Membership Category
One lump sum payment due upon registration
Training Group
10 Equal Monthly Payments via pre-authorized debit only.
2nd or 3rd Training Day
Registrant #4
Name

First Name Last Name
Birth Date

Month Day Year
Gender
Phone Number

Area Code Phone Number
E-mail
Name of School
Name of School
Emergency Contact
Other than Parent/Guardian above
Emergency Contact #

Area Code Phone Number
Care Card
Family Doctor
Allergies or Medical Issues
Other
Membership Category
One lump sum payment due upon registration
Training Group
10 Equal Monthly Payments via pre-authorized debit only.
2nd or 3rd Training Day
Should be Empty:

Evergreen Junior Academy

Registrant #1 Information

Registrant # 2

Registrant # 3

Registrant #4