Evergreen Junior Academy

Evergreen Junior Academy

Fall 2016 Registration
Parent #1 Name*

PrefixFirst NameLast Name
Parent #2 Name

PrefixFirst NameLast Name
Parent #1 Phone *

Area CodePhone Number
Parent #2 Phone

Area CodePhone Number
E-mail #1*
E-mail #2*
Address #1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Registrant #1 Information
Player

First NameLast Name
Birth Date

MonthDayYear
Gender
Phone Number

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

Area CodePhone 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 NameLast Name
Birth Date

MonthDayYear
Gender
Phone Number

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

Area CodePhone 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 NameLast Name
Birth Date

MonthDayYear
Gender
Phone Number

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

Area CodePhone 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 NameLast Name
Birth Date

MonthDayYear
Gender
Phone Number

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

Area CodePhone 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