Lake Country Soccer

Lake Country e-Registration System

Individual Soccer Registration Form

Please use the following form to register for Individual placement on a team looking for players or placement on a house team

This happens when:
1. an open space for a team is available in a suitable league or division and
2. a sufficient number of individual registrants to form a team (about 12-15) have registered.

General Information
Name:*	Gender:*
Age:*	Date Of Birth(mm/dd/yyyy):* Month: Day: Year:
Address:*	City, State, Zip:* City: St: Zip:
Home Phone:* - -	Work Phone: - -
Email Address: *	Confirm Email Address: *
Are you under the Age of 18?:* Yes No	If under age of 18, please supply Parent/Guardian's Name:
If you know of an adult who would like to help administer a youth house team, please indicate here:	In what capacity would this person like to help?:
Questions or Comments:
What Would You Like To Register For?
Session:*	Registration Type:*
Playing Level:*	Age Group:*	Team Gender:*
Payment Information (Refunded if you are not placed on a team)
Payment by check only. Make check payable to "Lake Country Soccer". Please be sure to write in the memo section, the program or activity being paid for. Please mail a copy of the registration confirmation page and your check to: Lake Country Soccer 2334 E. Pythian Drive Springfield, Missouri 65802

Individual Registration Submission Agreement
	I/we (above indicated) hereby acknowledge that I/we have reviewed this form and caused it to be electronically executed with the intent to be bound to the terms contained herein.

Note: Please do not press the "Submit Registration" button more than once.
Doing so may result in your credit card being charged twice.