Pay Your Session Fees Online

SPRING REGISTRATION with PAYPAL

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Home Phone (e.g. 408-777-1234 )

Mobile Phone (e.g. 408-777-1234 )

Gender*
Gender*

	Boy
	Girl

2012 Grade Level*
2012 Grade Level*

School*
School*

Parent/Guardian*
Parent/Guardian*

Health Insurer*
Health Insurer*

Health Policy Number*
Health Policy Number*

Emergency Contact Name:*
Emergency Contact Name:*

Emergency Contact Phone #*
Emergency Contact Phone #*

Agree to Use Internet Acces*
Agree to Use Internet Acces*

	Yes
	No

Check each box for multiple family member playing this season ($10.00 deduction)

	1
	2
	3
	4
	5

Approval to Post Child's Name (Roster and Verification)

	Approve
	Disapprove

I am ordering a new jersey.

	Yes
	No

Current Jersey Number

I would like to be considered to coach. If I volunteer to coach I agree to allow SCBA to conduct a confidential background check. The SCBA is dependent on competent and positive coaches volunteering their time and energy. The SCBA reserves the right to use high school age coaches if a qualified adult coach is not available.

	YES
	NO

Please enter the word that you see below.