Miami Beach Registration

Child's Information

Child's Name(Required)

First Last

Grade(Required)

Date of Birth(Required)

Age(Required)

Practice Day & Time(Required)

T-Shirt Size(Required)

Preferred Language(Required)

English

Espanol

Parent Contact Information

Father's Name(Required)

Father's Phone Number(Required)

Father's Email Address(Required)

Mother's Name(Required)

Mother's Phone Number(Required)

Mother's Email Address(Required)

Instagram @

How did you hear about us?(Required)

Social Media

Fliers/Signs/Banners

Friends & Family

Google

Child Insurance(Required)

Does your child have their own insurance policy?

Yes, they have their own insurance policy.

Program Selection

Product Name(Required)

GAMES PROGRAM IS CLOSED UNTIL JUN.

Bronze: $100/Month (PRACTICES) + $15 Uniforms

Uniforms(Required)

PRACTICE ONLY UNIFORM

Subtotal

Billing Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Shipping Address

Same as billing address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Total