Pierrefonds Soccer Association

Notice: Reminder to our members: Courses (programs) beginning with F are for girls/women, and courses beginning with M are for boys/men. If you are not creating a Family Account but rather an Individual Account for your child, please be sure to put the account in your child’s name or else you, the parent, will appear as the registered participant.

Step 1. Create Billing Contact

Step 2. Activate Account

Step 3. Account Activated

Contact Information Note: Red text indicates required fields.

Billing First Name:

Billing Last Name:

Address 1:

Address 2:

Address 3:

Country:

Prov/State:

City:

Postal/Zip Code:

Phone 1:

Phone 2:

Email:

Alternate Email:

Client #:

Preferred Language:

Account Information

Username:
		* We suggest your email address (Min Characters: 5)

Password:

Re-Type Password:

Password Strength

Note: For the best Password Strength rating include:

Uppercase and lowercase characters
Numbers
Symbols
Eight or more characters

Extra Information

Sex At Birth:

Male

Female

Decline to Answer

Birthdate:

Guardian 1 Name:

Guardian 1 Phone:

Guardian 2 Name:

Guardian 2 Phone:

Emerg. Contact:

Emerg. #:

Player's Medicare Card Number (If you are a parent, type N/A):

Medical Information

Family Doctor:

Dr. Phone:

Medical #:

List any medication presently taken:

Do you have any of the following conditions or requirements?:

Allergies:		Yes		No	Epi-pen Required:		Yes		No
Other Medical Conditions:		Yes		No

Please explain:

I attest that I have provided my name (if the player) and/or my child’s name (player) exactly as it appears on my or my child’s Medicare Card. I understand and agree that, if this is the first time I am registering with PSA, I must send a photo of the Medicare Card to PSA at info@soccerpierrefonds.ca as part of the registration process.

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