BSS BINTARO REGISTRATION FORM

Child’s Photo
*Session Venue :__________________
*Jersey Size :__________________
3X4 *Trial Date :__________________
*Filled out by coach

Child’s Details
Full Name : Muhammad Ammar Athar Arsyad

Date of birth and age : 03 Mei 2013

Full address : Puri Botanical Cluster Eugenia H5 no 23, Joglo, Kembangan, Jakarta Barat

______________________________________ Postcode: 11640

School : Citra Az - Zahra

Facebook : ______________________________ Instagram : __________________________

Have you ever joined : X No Yes, Club :

to a soccer/football/futsal club

Have you ever played

Futebol de Salão : Yes X No

Medical or special : X Fit Allergies Asthma

condition Heart Problem Epilepsy Others ......................

How do you know BSS : Website Social Media Internet

Magazine X Friends Brochure
BSS Member ........................... Other .......................
Parents’ Details
Name (Father) / Mobile : H M Arsyad Cannu
Name (Mother) / Mobile : Citra Kusuma Dewi
Home Phone : 0811 – 8183 - 2929
Email : Citra29kusuma@gmail.com
Facebook (optional) : ________________________ Instagram (optional): ____________________

Contact us for more information:

BSS Indonesia Head Office (HO) – Plaza Asia/ABDA, Lvl 26 Follow us @bssbintaro
Jl. Jend. Sudirman Kav.59, Jakarta Selatan
Tel No: +62 21- 514 01 679 Mobile: +62-8787 555 4115 (HO) Brazilian Soccer Schools Bintaro
Fax : +62 21 514 01222
Web : www.bssindonesia.co.id +62 82 1551 98 171 (BSS Bintaro’s phone and
WA)

bintaro@bssindonesia.co.id
 BSS BINTARO FEE REGISTRATION DETAILS

1. Registration Fee (once-off) : IDR 1,200,000(already include BSS Training Kit - a shirt, shorts and a pair
of socks)
*Training kit is compulsory to wear by the next session after received.

2. Monthly Fee (Choose one) : Mini 6 / U7 / U9 / U10 / U12 / U14 / U16

Price
Session Session / Duration Choose one
Program Age Group (Rupiah)
/month Week /session (√)
/month
Mini 6 4-6 4-5 1 60 min IDR 595,000

U7 6 -7 4-5 1 90 min IDR 695,000

U9 – U16 8 - 16 8 2 60 – 120min IDR 795,000

*All prices above are applied for 2022

Terms & Conditions

1. All payments should be transferred to Maybank account number 2145 26 36 56 of PT. Brasilindo Soccer.
2. All payments are non-refundable.
3. Membership is not transferable between children.
4. Registration and monthly fee payments should be finalized before the next training session.
5. All active members are entitled to participate in every event conducted by BSS Bintaro or BSS Indonesia.
6. Some training sessions might be conducted on hard surface, therefore suitable shoes are advised to be used for the
children.
7. BSS Bintaro’s training session(s) is/are can be re-scheduled, cancelled or moved to another type of venue due to extreme
weather or conditions, which all members will receive a notification message beforehand. Re-schedule or moving a
training session to another venue cannot be guaranteed as it will rely on, for instance, the availability of the replacement
venue or any other circumstances that cannot be controlled by BSS Bintaro.
8. In some cases, or extreme conditions (Force Majeure), re-schedule of training session(s) may not be possible.
9. Membership should be renewed with a charge of IDR 500.000,- (re-activation fee) if your monthly or absent fee payment
has not been received by BSS Bintaro for more than 2 (two) consecutive months.
10. Absence for a whole month is available and can only be taken 2 (twice) in a year with prior notice at least a week before
the preferred month is informed, with a fee of IDR 250.000/month and the child will be stated as ‘inactive member’
during the absent period. The amount of absence fee should be paid in advance to BSS Bintaro’s Maybank account as
stated in terms and conditions no. 1.
11. On a case-by-case basis, the length of absent and the re-activation fee in point 9 in this registration form, is open to be
discussed for those who are affected by long term illness or injury with proof of medical notes/report and/or treatments
from doctors or specialists involved.
I, hereby agree to these terms & conditions and give my permission for my child to train/play with Brazilian Soccer
Schools Bintaro and authorize the coaches and staffs of Brazilian Soccer Schools Bintaro to act according to their best
judgment on any emergencies situations that required medical attention or treatment. I also release BSS Bintaro’s
coaches and staffs from any liabilities and bills (including hospital bills) for any injury or any illness that might
occurred to my child caused by attending training session(s) or tournament(s) in the future.

Signed ___________________________ (parent’s signature required)

Name___________________________________________________ Date: _________/_________/__________

Contact us for more information:

BSS Indonesia Head Office (HO) – Plaza Asia/ABDA, Lvl 26 Follow us @bssbintaro
Jl. Jend. Sudirman Kav.59, Jakarta Selatan
Tel No: +62 21- 514 01 679 Mobile: +62-8787 555 4115 (HO) Brazilian Soccer Schools Bintaro
Fax : +62 21 514 01222
Web : www.bssindonesia.co.id +62 82 1551 98 171 (BSS Bintaro’s phone and
WA)

bintaro@bssindonesia.co.id