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Individual Registration

Youth Competitive Soccer

Age *

Date of Birth - Youth *

Date of Birth - Adult *

Player First Name *

Player Last Name *

Parent/Guardian Name *

Postal Code *

Phone *

Cell Phone

Email *

Pictures Permission *

Yes

No

Payment Information

Amount

$

Payment Method

Credit Card Number*

Expiration Date*

/

Card (CVV) Code*

Card Holder Name*

613-863-8142

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