Registration Information
Programs: Central City Breakers Revolution Development Programs
Season: Fall & Winter Semester
Dates: September 2011 – March 2012
Open to: Boys & Girls
Age Group: U9 – U18 (check camp description for age group)
Levels: Advanced (Metro/Gold/Select)
Development (Silver/Bronze/Red/Blue/Open)
Contact: Paul Bahia, Executive Director: paulbahia@surreyyouth.com.
NOTE: Please enter all required fields below. You will receive a confirmation email upon successful form completion. If not, please email CCBR Executive Director at paulbahia@surreyyouth.com.
"*" is a required field
1. Player Information:
*First name:
*Last name:
*Birthdate:
*Age Group:
*Current Team:
*Gender:
*Shirt Size:
*Short Size:
2. Main Contact Info:
*First Name:
*Last Name:
*Phone (main): ()
Cellular (main): ()
*E-mail:
*Street:
*City:   Prov: 
*Postal Code:
*Medical Concerns?
3. Registration Info:
*Program:
Program Cost: $
Total Cost: $
* Waiver: I/We, the legal guardian(s) of the above named player, approve their participation in the CCBR activities. We also agree that the Central City Breakers Football Club (CCBFC), Surrey Youth Football Club (SYFC), Central City Breakers Revolution (CCBR), nor any sponsors, coaches, managers, assistants and others involved will not be held responsible for any accidents or loss, and agrees to release any and all claims, demands and suits that may arise all coaches/managers for all claims and damages which may arise as a result of/or by reason of such accident or loss.
Payment method: