Welcome to Claremont AYSO Region 3

Last Name:

First Name:

Player's First Name:

Player's Last Name:

Player's Birth Date:

Player's Gender: Boy Girl

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Season:  (Please indicate the season such as Fall 2008, Spring 2008, etc.)

Date of Payment:

Method of Payment:  Online Check 

                                    Visa     Master Card    American Express     Discover

                                               First Four digits of credit card number   Last four digits:

Reason for refund:             

                                                                                                                     


                                       Signature____________________________________________________    Date_____________________


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