GRADE 8 (BASIC) REFEREE CLINIC REGISTRATION FORM   August 12, 14, 15   2010

Last Name: _______________________________________

First Name: _______________________________________

ADDRESS: _______________________________________

                    _______________________________________

CITY: ____________________________________   TX

ZIP CODE: _______________________________

GENDER:  ___ (M or F)  DATE of BIRTH: _____(m) _____(d) ______ (Y)

EMAIL: ___________________________________________________

PHONE: __________________________  (home)

PHONE: __________________________  (cellular)

Home Soccer Association: __________________________________________

Submit with Class Registration Fee ($25.00, payable to KSA) to:

Keller Soccer Association,   PO Box 462,  Keller TX  76244

Questions?    KSA       kellersoccer@verizon.net

Office Use Only:

Date Recvd. ___________________________________

Check No. _____________________________ (correct amt?) Y___