CISA CLUB Online Registration

2018-19 WINTER / SPRING ONLINE REGISTRATION IS ACTIVE for high school ages and 8th grader boys. Please contact Tim at tregan@fsmail.bradley.edu with questions about paying via check or cash.

Step 1 of 3

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Player Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Home Phone*
Cell Phone
Birth Date*
MM
DD
YYYY
Age*
High School Name*
Current Grade / HS Grad Year*
GPA/ACT/SAT

Parent Contact Information
Mother's Name*
Mother's Phone*
Mother's Email*
Father's Name*
Father's Phone*
Father's Email*
Home Phone*
Emergency Contact Information
Please list two emergency contacts*
Name Home Phone Cell Phone
Medical Release Form
It is the responsibility of the participant’s parents or legal guardians to ensure that the participant is healthy and has no physical problems which would prevent the participant’s participation in soccer activities. Responsibility for primary medical insurance coverage rests with the participant or their parents or legal guardians.
Medical Insurance Company*
Policy Holder*
Policy Number*
Special Medical Needs
Do you certify that this player has had a physical examination by a licensed physician in the past year and is free from any illnesses or injuries that would prevent the participant from participating in any activities at the Central Illinois Soccer Academy.*
- Yes

Registration Options
Please select*
Billing Information
Total To Be Charged To Card
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Total
$0.00
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Name	Home Phone	Cell Phone

CISA CLUB Online Registration

Step 1 of 3

Parent Contact Information

Emergency Contact Information

Medical Release Form

Registration Options

Billing Information