Registration Form - Summer Soccer Camp 2022

Athlete Information

Age Group/Camp Session*

Athlete's Name*

First NameLast Name

Birth Date*

MonthDayYear

Preferred Pronoun / Title

ex: she/her/hers

Address*

Street Address

City Province

Postal CodeCountry

Parent/Guardian Information

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

E-mail*

Emergency Contact Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Does the athlete have any allergies, chronic illness and/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 Grassie Soccer School of Excellence during the selected camp. In exchange for the acceptance of said child’s candidacy by Grassie Soccer School of Excellence, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Grassie Soccer School of Excellence and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against Grassie Soccer School of Excellence. 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 soccer. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Consent For Use Of Personal Information I hereby certify that I am the parent or guardian of the above-named minor who is under the age of 18 years. For the consideration above, I consent that any images of the minor, recordings of the minor’s voice, use of the minor’s name and/or descriptions of the minor which have been or are about to be recorded by or on behalf of the Grassie Soccer School of Excellence may be used for promotional purposes such as displays, the media of newsletters, websites, television, film, radio, print, and/or other form.

I also give Grassie Soccer School of Excellence permission to contact me by email and/or phone for emergengy and promotional use.

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*

Grassie Soccer School Of Excellence