USA U23 Women Registration Player Name First Middle Last Gender Male Female Age Date of Birth MM slash DD slash YYYY Years played for BFLA: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneYour Email Highest Level of Education Attained Years of Playing Experience Who is your current or previous team? Highest Level PlayedYouthHigh SchoolCollegeSemi-ProProWhat do you hope to achieve through this program?What are your goals soccer wise?Athlete Shirt Size Youth Small Youth Medium Youth Large X-Small Small Medium Large X-Large Other Athlete Short Size Youth Small X-Small Small Medium Large X-Large Other Position How did you hear about this program? Friend or Family Coach Social Media Other Emergency Contact InformationEmergency Contact Name First Last Emergency Contact Email Emergency Contact Cell PhoneEmergency Contact Work PhoneEmergency Contact Home PhoneSignatures, Disclaimers and Terms of AgreementMedical Expenses(Required)I understand that the Bascome Enterprise and/or its Staff will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility. I agreePhoto Release(Required)I understand the photos will be used to keep a journal of activities, to share during power point presentations, for promotional purposes including flyers, brochures, newspapers and/or reports to our donor Bascome Enterprise. I agreeTerms(Required)The Bascome Enterprise and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless you are unable to participate due to an accident or illness per physician orders. Your photos and quotes may be used for publicity purposes. I agreePayment Terms(Required)The U23’s are a 2 month program (June-July) Registration is due by May 1st Full payment is due before the first day of program (Thursday, June 2nd) I agreeSignatureBy typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. First Last Date MM slash DD slash YYYY Payment InformationPayment Options Registration Fee ($250) Full Payment ($400) Total Credit CardCard Details Cardholder Name CommentsThis field is for validation purposes and should be left unchanged.