MSA Day Camp
2008 Field Player & Goalkeeper Registration
Ages 6-18
Complete the form below, then press the "Submit" button.
Midwest Soccer Academy Accepts Check or Mastercard/Visa Payment.
Required Fields are Marked with a "*" Use Proper Punctuation, Please Turn Off All Caps.

All MSA campers receive (1) t-shirt and a water bottle.

Select the Camp Session You Would Like to Attend*:
Personal Information:
Please Note: The Email address below will be used as the main means for all future camp communications.
Proper Punctuation is Required, i.e.: "John Smith", NOT "john smith" or "JOHN SMITH"
First Name* Last Name*
Date of Birth*
Month    Day    Year   
Street Address*
City, State, Zip*
Contact Email Address*
Home Phone*
( ) - -
Gender*
 School Grade (as of 01/01/08)* ie: Fifth
Have you attended a Midwest Soccer Camp before?*
Yes No		 T-Shirt Size*
Youth Large
Adult Small Adult Medium
Adult Large Adult X-Large
Position*
Field Player Goalkeeper 		 
Club
  
Parent Name(s):
  
Payment Information

Discount Code:
Leave Blank if you do not have a "Discount Code"

Your Camp Fee: $

Payment Method:* Check Credit Card

Payment Option: Pay in Full Now Payment Plan

If Payment Plan is allowed for this camp, then you may select it above.
Payments will be divided into equal payments with a a $3 processing fee for each payment.
The first payment is now.
The 2nd payment, which will be on 12/15/2009.
The last payment will be $ plus the processing fee.

Payment Plan must use Credit Card. Be sure you use a credit card that does not expire until after all payments are made. Thank you.

Amount of This Payment: $

Name as it Appears on Credit Card Credit Card Type
MasterCard Visa
Credit Card Number


 Credit Card Expiration Date
 /
Credit Card Holder's Street Address:
Credit Card Holder's Zip Code:
Agreement for Electronic Submission
I/we (above indicated) hereby acknowledge that I/we have reviewed this form and caused it to be electronically executed with the intent to be bound to the terms contained herein.*
 



Please click ONLY ONCE on the Submit button above.
Your Credit Card will be charged each time you press submit.
Sometimes, it takes a few seconds for the form to be processed. Thank you.
Please email to Info@MidwestSoccer.net if you have any problems.


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