WBBC Soccer Clinic Registration 2025

WBBC Soccer Clinic Registration
CHILD INFORMATION:
Child Name*

First NameLast Name
Birth Date*

MonthDayYear
Male/Female*
Age*
Name of School
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
MEDICAL INFORMATION
Physician Name

First NameLast Name
Phone Number

Area CodePhone Number
Medical Concerns
Parental/Guardian Consent
By submitting the form, I, as the parent/guardian of the registrant, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may given under whatever conditions are necessary to preserve the life, limb, or well-being of registrant.

By submitting the form, I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of West Broadway Baptist Church, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for West Broadway Baptist Church, accepting the registrant for its soccer programs and activities (the "Programs"). I hereby release, discharge and/or otherwise indemnify West Broadway Baptist Church, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claimby or on behalf of the registrant as a result of the registrant's participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize.

WBBC Soccer Clinic Registration

CHILD INFORMATION:

PARENT/GUARDIAN INFORMATION:

MEDICAL INFORMATION

Parental/Guardian Consent

Payment