NAME:                                  SCHOOL NAME:  

HOME ADDRESS:          CITY:      STATE:     ZIP: 

SCHOOL ADDRESS:      CITY:      STATE:     ZIP: 

HOME PHONE #:                  CLASSIFICATION:  Public 4A Public 3A Public 2A Public 1A Private 3A Private 2A Private 1A

SCHOOL/WORK PHONE #: 

CELL PHONE #: 

FAX #: 

E-MAIL ADDRESS:    OR 

ARE YOU THE:            HEAD COACH                    ASSISTANT COACH    

NAME OF ASSISTANT COACHES: 

WHAT PROGRAM DO YOU WISH TO REGISTER?

      BOYS        $40 EACH SEASON.

      GIRLS       $40 EACH SEASON.

      BOTH BOYS & GIRLS      $70 EACH SCHOOL YEAR.

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 MEMBERSHIP NUMBER?         

MAKE CHECKS PAYABLE TO "NCSCA" AND SEND IT WITH THIS FORM TO YOUR REGIONAL CHAIRMAN.