Select the age bracket for your child
Clubber's Name *
Clubber's Name
Birthdate
Birthdate
Parent/Guardian Name *
Parent/Guardian Name
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Emergency Contact
Emergency Contact
Emergency Contact Phone
Emergency Contact Phone
2nd Emergency Contact
2nd Emergency Contact
2nd Emergency Contact Phone
2nd Emergency Contact Phone
Attended Soccer Camp
I give Midway Baptist Church permission to use my child photo in a newsletter or in the churches Facebook page