On-Line Registration  
Valencia Soccer Academy
300 Open Range Ave SW
Los Lunas, NM 87031

Child Name:*
Birth Date:*
Level of Play:*
Boy Girl

Primary Contact Relationship:
Father Mother Other
Primary Contact Name:*
Email Address:*
Primary Contact Street Address:*
Primary Contact City:*
Primary Contact State:*
Primary Contact Zip Code:*
Home Phone:*
Cel Phone:
Secondary Contact:
Father Mother Other
Secondary Contact Name:
Secondary Email Address:

Willing to Sign a Liability Waiver:
Yes No
Name of Person Completing the Application:
* Required