Account Holder Information

First Name * * Required Field
Last Name *
Address *
City *    State *    Zip *
Home Phone * () -
Mobile Phone () -
Work Phone () - Ext

Alternate Point of Contact (copied on all emails)

First Name
Last Name
Email

How did you hear about Keiki Soccer?


Email Subscription Preferences

Per our policy, we'll always send emails for classes cancelled due to weather.
Promotions New class details, newsletters and important updates
Child Birthday Happy birthday wishes for each child on their special day

Child Information

1 FirstName *
Middle Name
Last Name *
Birthdate *
Gender *
Relationship *
School
Emergency Contact Name *
Emergency Contact Phone *
() -
Pediatrician Name
Pediatrician Phone
() -
Medical Condition(s)
Please indicate any relevant medical conditions or allergies your child may have (not required if your child has no relevant medical issues)
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Login Information

Email *
Password *
Password (Confirm) *
Password must be at least 6 characters long with 1 capital letter and 1 number.