SCHOOL NAME:  

NCSCA Region:  1 2 3 4 5 6 7 8 9 10 11             School Classification:  Private Public 1A Public 2A Public 3A Public 4A

SCHOOL ADDRESS:      CITY:      STATE:     ZIP: 

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NAME of Boys Head Coach:   

HOME ADDRESS:          CITY:      STATE:     ZIP: 

HOME PHONE #:                 SCHOOL/WORK PHONE #: 

CELL PHONE #:                   FAX #: 

E-MAIL ADDRESS:    OR 

NAME OF Boys ASSISTANT COACHES: 

ARE YOU A CURRENT MEMBER OF THE NATIONAL SOCCER COACHES ASSOCIATION OF AMERICA?

     YES                          NO             IF NO, YOU CAN JOIN AT www.nscaa.com

IF YES, WHAT IS YOUR NSCAA MEMBERSHIP NUMBER?       

--------------------------------------------------------------------------------------------------------------------------------------------------------------------If the Girls coach is the same as the Boys Coach - put "Same" in the Name box and proceed to the next section.  

NAME of Girls Head Coach:         

HOME ADDRESS:          CITY:      STATE:     ZIP: 

HOME PHONE #:                 SCHOOL/WORK PHONE #: 

CELL PHONE #:                   FAX #: 

E-MAIL ADDRESS:    OR 

NAME OF Girls ASSISTANT COACHES:     

ARE YOU A CURRENT MEMBER OF THE NATIONAL SOCCER COACHES ASSOCIATION OF AMERICA?

     YES                          NO             IF NO, YOU CAN JOIN AT www.nscaa.com

IF YES, WHAT IS YOUR NSCAA MEMBERSHIP NUMBER?      

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WHAT PROGRAM(S) DO YOU WISH TO REGISTER?

      BOYS        $40 EACH SEASON.

      GIRLS       $40 EACH SEASON.

      BOTH BOYS & GIRLS      $70 EACH SCHOOL YEAR.

      MAKE CHECKS PAYABLE TO THE "NCSCA"

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If you are a FIRST TIME member of the NCSCA, your membership is FREE for your FIRST SEASON as long as you are SPONSORED by a current NCSCA Member.  Please fill out this section if you have a Sponsor.

Sponsor's Name: 

School Name:     

HOME PHONE #:                 SCHOOL/WORK PHONE #: 

CELL PHONE #:                   FAX #: 

E-MAIL ADDRESS:    OR 

MAKE CHECKS PAYABLE TO THE "NCSCA" AND SEND IT TO:
BRIAN JILLINGS
HICKORY HIGH SCHOOL
1234 3RD STREET NE
HICKORY, NC 28601