NEW PARTICIPANTS ONLINE REGISTRATION


Returning Participants:
Click here to register online

Instructions

Please fill out every step of the registration process
The process is complete when you see a Registration/Payment Confirmation.

Fields with a * must be completed before you can move to the next page.
Click on the Continue button to go to the next page

If you have already registered with Just for Kicks and would like to purchase additional sessions please click here.


*Name
Occupation
*Home Phone Number Work Phone
Cell Phone
*Date of Birth
Email Address (Important! You will receive Just For Kicks information here.) *I am currently playing soccer.
Yes
No
*I rate my soccer Level as:
*How did you hear
about Just For Kicks?		 Referred By:
*My main goal is:
*This is my first time at Just For Kicks
Yes
No
If you answered "no", when was the last time you attended:
*Name of Emergency Contact *Phone Number
*T-Shirt Size
Select how many days per week you are interested in attending.

One Day/Week Two Days/Week Three Days/Week Trial Session
Medical Information
*1. Are you allergic to any medication (aspirin, penicillin, sulfa, etc.)? List Medications
*2. Do you take any prescribed medication on a permanent or semi-permanent basis? List Medications
*3. Do you have diabetes?
*4. Do you have high blood pressure (hypertension)?
*5. Do you have asthma?
*6. Describe any severe injuries within the past 5 years or that may still cause pain:
7. Detail any surgical procedures:
*8. Do you have any conditions that may
make it unsafe for you to participate in a
soccer fitness program?
If yes, please explain
If paying by check, please make payable to Just For Kicks.
Mailing address:
Just For Kicks
2500 E. Imperial Highway, Ste. 201 #168
Brea, CA 92821
NOTICE: It is wise to seek your doctors advice before beginning any health/fitness/nutrition program!

*By selecting I Agree below, you agree to the above terms and conditions

I Agree I DO NOT Agree
 

I agree to allow Just For Kicks Fitness to autobill my credit card monthly. I understand that I can cancel my membership anytime (as long as it is after the membership duration I choose, and prior to my next monthly billing date). Billing dates will be the same each month depending on start date.

*
I Agree I DO NOT Agree
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