Michigan Burn Soccer

30845 23 Mile Road Chesterfield MI 4807 Phone number: 586.949.6266 http://www.michiganburnsoccer.com

Online Player Registration Form

Parent or Guardian Name:

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Player's Name:

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Player's Date of Birth

Player's Age:

Must be a whole number

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Player's Gender:

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Please select one of the following options

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Address:

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City:

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State:

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Zip Code:

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Home phone number:

Must be a number

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Cell phone number:

Must be a number

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E-mail address:

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If you selected Friend, Travel League or Other, please list specific name here:

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Comments:

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I hereby give permission and certify that team members are in good health and able to participate in all Michigan Burn activities. By selecting the SUBMIT button, I release coaches, staff, and all others associated with Michigan Burn activities of all Liability for any injury or illness incurred by team members at Michigan Burn activities.