Sports Blast: Southern Illinois' Premier Sports Experience

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Facility Hours:
(Oct-Apr)
Mon-Fri 9am-8pm
Sat 9am-5pm
Sun 12pm-5pm

(May-Sep)
Mon-Fri 9am-7pm
Sat 10am-5pm
Sun 1pm-4pm

Tel.529-5511

Youth Indoor Soccer League Registration

Contact Information

Individual Contact Information
First Name
Last Name
Parent/Guardian
School
Grade (K-8)
T-Shirt size
Gender	Male Female
Address
City
State
Zip
Home Phone
Business Phone
Cell Phone
Email address

Scheduling Limitations

Please let us know of any scheduling limitations you may have due to other activities.

Online Payment Information

Payment Amount:

Card Type:

Name on Card

Card Number: (no spaces)

Expiration:

Month	Year

For your protection please provide your credit card security code.

Security Code:

How to find your security code:

The security code is on the back of MasterCard, MasterCard, and VISA cards.
The security code is on the front of American Express cards.

All players are required to complete the Player's Waiver and Release of Liability Form
Forms are available online at www.SportsBlast.net/docs/waiverform.pdf or available at Sports Blast location

©2004 Sports Blast, LLC
1215 E Walnut St, Carbondale, IL 62902-3427 · 618-529-5511 · info(at)SportsBlast.net
Facility Hours: 8:30am-9pm Mon-Fri; 9am-4pm Sat; Noon-4pm Sun