Registration Form

Parent's Name*

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Child's Name*

First NameLast Name

Age Groups*

Under 5 (Boy or Girl)Under 8 (Boy or Girl)Under 11 (Boys only)Under 14 (Boys only)

Preferred Time on Tuesdays/Thursdays*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact*

Please enter a valid phone number.

ACKNOWLEDGEMENT AND RELEASE FORM

I, the applicant, on behalf of myself, members of my family, my heirs, executors, administrators and assigns, hereby forever release, discharge and hold harmless Guildford Islamic Cultural Centre and Young Champs, representatives and agents for any injury, loss or damage to my person or property howsoever caused, arising out of or in connection with my taking part in the GICC United Soccer Program (herein referred to as "the Program") and activities and notwithstanding that the same may have been contributed to or occasioned by the negligence of Guildford Islamic Cultural Centre and/or Young Champs, representatives or agents.

The undersigned acknowledges that:

- He/She is desirous of using, as a registered member, the Program at Guildford Islamic Cultural Centre
- He/She has received a completely executed copy of this agreement.
- He/She confirms that there were no verbal presentations other than those specified in this agreement.
- He/She will be playing the sport of soccer in an outdoor field
- He/She may be photographed or filmed while attending the Program and he/she gives permission to Guildford Islamic Cultural Centre, and any affiliates to use any and all photos, video footage, and/or video streaming for promotional, sales, publicity, and advertising purposes for all media including internet.
- The waiver was read and he/she agrees to abide by it.

I agree with the above acknowledgement and release form and give consent to my child to participate*

Yes

Payment*

GICC United Soccer Program$120 Monthly Fee + $25 One time registration fee

$145.00CAD for the first month then,$120.00CAD for each month

Email

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration