May Ethnos Soccer Clinic Registration Form

FREE Registration! Free Food! Free Games!

The Soccer clinic will be on May 14th at Cottonwood Park.

Check in starts 10:00a.m. and event ends at 12p.m.

The clinic is open to grades: K-6th.

Come warm up with skills, play soccer and eat some free food.

Please feel free email if you have any questions.

Things to bring: Water bottle and soccer ball if you have one.

Location: Cottonwood Park ( we will be set up in the front of the park. Near the entrance of the park at Beltline).

Address: 1301 W Belt Line Rd. Richardson 75080.

Email: debbie@ethnoschurch.org

Contact: Debbie

Ph: 972-231-2062

Athlete's Name

First Name Last Name

Athlete Information

Age

Grade

Type a question

Parent/Guardian Information

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

E-mail

Cell Number *

Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Ethnos Bible Church during the selected clinic. In exchange for the acceptance of said child’s candidacy by Ethnos Bible Church., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Ethnos Bible Church and all its respective volunteers, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected clinic sessions. In case of injury to said child, I hereby waive all claims against Ethnos Bible Church including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Is the athlete prescribed an inhaler? If yes, please explain any instructions.

Medical Release and Authorization As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the Ethnos Bible Church and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

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