Empire State FC Waiver Form
Particapant Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Boy
Girl
Grade
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Other
What School does the participant attend?
*
What program are you registering for?
*
Elite Development Player League
Free Soccer Clinic
Skills Academy
Utica Community Club
Not Sure
Player Shirt Size?
*
Youth Large
Youth Meduim
Youth Small
Youth Extra-Small
Other
Player Short Size?
*
Youth Large
Youth Meduim
Youth Small
Youth Extra-Small
Other
Would you like to be updated about individual and small group training opportunities through our Empire State Skills Academy?
*
Yes
No thank you
Maybe
Parent/Guardian Contact
Parent Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
*
First Name
Last Name
Relationship to Player
*
Phone Number
*
Please enter a valid phone number.
Medical Information
Known Allergies
*
Medical Conditions
*
Medications
*
Physician Name & Phone (optional)
Back
Next
Player Media Release
I understand that photos or videos of my child may be taken during the course of activities. By signing this form, I grant permission for Empire State FC to use these images for promotional purposes such as social media, website content, and print materials. If I do not wish for my child’s image to be used, I understand that I must notify Empire State FC in writing prior to participation.
I agree to the media release terms (Initials):
*
Child’s Liability Waiver
I acknowledge that participation in soccer includes a risk of injury. I hereby release, indemnify, and hold harmless Empire State FC, its directors, coaches, volunteers, and facility owners from any and all claims, liability, or damages arising from my child's participation in with Empire State FC. I confirm my child is in good health and able to participate in physical activity.
I agree to the liability waiver terms (Initials):
*
Emergency Medical Consent
In the event of an emergency where I cannot be reached, I authorize Empire State FC staff to obtain necessary emergency medical care for my child.
I agree to the emergency medical care (Initials):
*
Parent or Guardian Acknowledgment
Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: