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)*

Phone*

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.