Participant's Name:
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Age as of December 1
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Please Select
4
5
6
7
8
9
10
11
12
Program:
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Please Select
Li\'l Kickers - NEW REGISTRANT ($75)
Li\'l Kickers - Returning Star Discount ($50)
Parent(s) Name(s):
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Parent's E-mail:
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Street Address:
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City:
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State:
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Please Select
NJ
PA
NY
Zip code:
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Home Phone:
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Parent's Cell #:
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Emergency Contact Name:
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Emergency Contact Phone #:
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Allergies, Other Info, Etc.
By clicking the "Submit" button below, you acknowledge that you are giving your approval for this applicant to participate in this NLSA program. As such, you hereby waive, release, absolve, indemnify and agree to hold harmless the sponsors, organizers, participants, and persons involved in the organization and operation of this program, as well as the owners and agents of the facilities utilized for this program, for any claim arising out of injury to the named participant or any other member of his/her family who may be participating as a spectator.
------- If your child is currently participating in our Li'l Kickers program, you can bring your confirming email and your check to the next session. If you're a NEW REGISTRANT, please mail a copy of your confirming email, along with your check for $75 to NLSA, 3 Spring Hollow Drive, Hopewell, NJ 08525.
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