PASC Online Registration Form

Player's Name:   (Last)    (First)    (M.I.)

Address      City   

State       Zip

Home Phone:   (Area Code)    (Number) -    

E-Mail Address

Social Security Number --

Date of Birth       19          Country of Birth

Health Insurance Company    Policy Number 

Gender   Male   Female

Division

Team (joining or returning to)

*IF your team's not listed, have your Team Rep contact me immediately to add it to the list (rod@pensacolasoccer.com).  Meanwhile, fill in the next blank.  Thanks!

Name of Team (only if a New Team)

Jersey Needed

Jersey Size

If someone else is paying for you, please enter theiR full name here:*

*This is VERY IMPORTANT!  The name we receive with the payment is the owner of the credit card.  We need to know if it's different, so we can match the payment with your registration!  Please fill this in if someone else is paying for you!!!

Signature (Your submission of this online form takes the place of your signature.  It confirms that you have read

               and understand all of the rules and regulations of the league.  It also confirms your full understanding

               of the Release of Liability Waiver.)

 ---Call 324-3289 or e-mail rod@pensacolasoccer.com  if you have any questions.---

If you made some mistakes, just click the following button:

Once you've completed the form, just click the "Submit" button below.  You will be linked to a page showing you a copy of your submitted form.  Then, at the bottom of that page, you will be able to pay by credit card (MasterCard, Visa, Discover Card or American Express).

If you do not pay your fees, you will NOT be registered!  1st to pay = 1st to play!