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TDKicking Academy
Specializing in ElitePreparation®

Registration Form

PLEASE COMPLETELY FILL OUT THIS FORM BEFORE SUBMITTING

PAYMENT MUST BE RECEIVED IN FULL NO LATER THAN:
48 HOURS prior to the start of a session and ONE WEEK prior to the start of a camp.

First Name:
Last Name:
Session:
Birth Month:
Birth Year:
Street Address:
City:
Zip Code:	(5 digits)
State:
Daytime Phone:
Email:
School Name:
Grade:
Position:
Tee Shirt Size:
Payment:

Name on Card:
Credit Card Number:
PVC # (back of card):	(3 Digits)
Billing Address: