Personal Information

Parent/Guardian (First & Last)*

2nd Parent/Guardian (First & Last)*

Email Address*

Please Retype Your Email Address*

Street, City/Town & Postal Code*

Phone Number*

Emergency Contact Information
Name (First & Last)*


Alternate Phone

Family Dr. (Optional)

Lil' Kickers Information
Number of Children You'd Like to Register

1st Lil' Kicker                 Birth Date*

Preferred Time Slot             

2nd Lil' Kicker        Birth Date
        Preferred Time Slot             

Special Concerns (Allergies, Meds, Conditions)*

Photographic Release**             


For your convenience, you may sign your child/children up for Lil' Kicks soccer instantly using the on-line form on this page!  Once the on-line form has been sent successfully, you should receive a confirmation message.

If you have more than 3 children to enroll, please contact us by phone or email.

*Any allergies or medical conditions listed will remain confidential unless otherwise requested by the Child's guardian.

**In the future, this website may contain images taken during class time. Answering "Sure, No Problem" to this question gives your consent to post images of your child on the website.