100% Soccer, Inc.

Summer Soccerthon
On-Line Registration


Complete Form, Click "Continue To Next Step" to pay by Check, Credit Card or PayPal.

Note: This form is best viewed at 1024x768 px resolution or higher.
Upon completion of the form you must click on "Continue to Next Step" to process your registration.
If you do not receive an e-mail confirmation, your form may not have been processed. Call 631-286-2255 for assistance.

All Fields Required Except Where Noted as Optional
Team Name

Team Gender
Boys   Girls
Team Age Group (This Coming Fall)
Recreational   Travel - Div:
Division in Which You Would Like to Compete
Fee: $
Coach's Last Name
Coach's First Name
Home Phone # (xxx-xxx-xxxx)
Street Address
Work Phone # (xxx-xxx-xxxx) (Optional)
Town
State
Zip Code

Cell Phone # (xxx-xxx-xxxx) (Optional)
Email Address

Fax # (xxx-xxx-xxxx) (Optional)
Alternate Contact Name
Alt. Contact Telephone # (xxx-xxx-xxxx)
Alternate Contact Email Address
Alt. Contact Cell # (xxx-xxx-xxxx) (Optional)
Notes
Promotion Code:

All requests for specific division or date play are subject to availability and competitive considerations by Soccerthon officials.


 

To Pay With
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