Champions Soccer Academy

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Player Registration

PLAYER INFORMATION

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Home Phone:

* Birthdate:

* Email:

Gender:

Grade:

PARENT/GUARDIAN #1

Firstname:

Lastname:

EMail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact:

* Phone:

* Relationship to Player:

* Insurance Carrier:

* Policy #:

WAIVER INFORMATION

Parent/Guardian Consent Form:
I do hereby expressly and specifically assume all risk which attend the game of soccer and any sports or related activities, including but not limited to physical contact and physical injuries. I agree to indemnify and hold harmless the Champions Soccer Academy, its officials, members, and its affiliates including but not limited to adjoining facilities from any and all claims, suits, or proceedings arising allegedly or in reality out of the acts or omissions and participation of the undersigned in any related activity. I also agree to all rules and regulations of the Champions Soccer Academy.

Consent for Medical Treatment (minor):
As the parent or legal guardian of the above player, I hereby consent for emergency medical care prescribed by the duly licensed doctor of medicine or dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of this minor, named above.

I/we agree with the above *

Signature:

Date:

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