Gino's Soccer Academy

Please fill out our online registration form below and send your payment, or $50 per player deposit, via regular mail to:
Gino's Summer Soccer Jam, P.O. Box 1582, Lafayette, CA 94549-1582

For Credit Card payments please print off the Printer Friendly Form and send via US Mail.

Note: when you hit the register button at the end of the form it will open your email application and send the information by email. If you prefer to send a form via the U.S. Postal Service click here for a printer friendly version of this registration form.


Camper #1 Name:
Age:
Sex:
Years Playing & Experience Level:
Camp Location:
Camp Date:
Camp Type:
Teammate Request: (Request to be in the same group as a friend)

Camper #2 Name:
Age:
Sex:
Years Playing & Experience Level:
Camp Location:
Camp Date:
Camp Type:
Teammate Request: (Request to be in the same group as a friend)


Parent Name:
Email Address:
Address:
City:
State:
Zip:
Phone:
Emergency Contact:
Emergency Contact's Phone:


Doctor's Name:
Doctor's phone:
Alergies/Medications: (please indicate for which camper if more than one child is attending)


Payment: ( Note: deposits shall be $50 per player with balance due on the first day of camp )
Amount Paid:

Please send your payment or deposit via regular mail to: Gino's Summer Soccer Jam, P.O. Box 1582, Lafayette, CA 94549-1582 For Credit Card payments please print off the Printer Friendly Form and send via US Mail.