CISA Club Online Registration

If you prefer to pay via check, please fill out the registration form (click here) and return the form to Tim Regan at tregan@fsmail.bradley.edu.

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Parent Contact Information
Parent/Guardian Name*
Parent/Guardian Phone*
Parent/Guardian Email*
Parent/Guardian (2) Name
Parent/Guardian (2) Phone
Parent/Guardian (2) Email
Home Phone (optional)
Emergency Contact Information
Please list two emergency contacts*
Name Cell (or home) 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

Name	Cell (or home) Phone

Parent Contact Information