Clone of 2024/25 Winter Academy

Participating Athlete's Information
Athlete's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade for school year 2025/2026*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Cell Number*
E-mail
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*
Alt. Phone Number
Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the athlete prescribed an inhaler? If yes, please explain any instructions.
T-shirt Size

YOUTH MEDIUMYOUTH LARGESMALLMEDIUMLARGEEXTRA LARGE
Informed Consent and Acknowledgement

I hereby provide my consent for my child's participation in all activities organized by the Uppr9t Staff during the chosen academy. By accepting my child's participation, I acknowledge and accept all the potential risks and hazards associated with these activities. I release, exempt, and indemnify Uppr9t Soccer, Carlisle School and all its officials, representatives, coaches, athletes and agents from any responsibility for injuries that may occur to my child during their travel to, engagement in, or return from the academy sessions.

If my child sustains an injury, I waive any claims against Uppr9t Soccer, Carlisle School, including its coaches, affiliates, fellow participants, supporting organizations, advertisers, and, if applicable, the owners and landlords of the premises where the event is held. Engaging in sports activities, including soccer, inherently carries a risk of injury, which may include but is not limited to fractures, paralysis, or even fatality.
Signature*

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Date*

MonthDayYear
Date
Medical Release and Authorization

As the legal guardian of the youth athlete listed, I hereby grant permission for qualified and licensed medical professionals to diagnose and administer treatment in the event of a medical emergency. This authorization is applicable when, in the medical professional's judgment, immediate attention is necessary to prevent further harm to the minor child's life, physical appearance, physical functionality, or to alleviate undue pain, suffering, or discomfort should there be a delay in treatment.

I hereby give consent to the attending physician to undertake any necessary medical or minor surgical procedures, conduct X-ray examinations, and administer immunizations to the youth athlete named. In cases of a serious illness, the requirement for major surgery, or significant accidental injury, I am aware that the attending physician will make every reasonable effort to contact me as swiftly as possible before proceeding with treatment. This authorization is granted after a reasonable attempt has been made to reach me.

I also authorize the affiliated individuals, including Directors, Coaches, and Team Parents, to provide essential emergency treatment before the child is admitted to a medical facility.

This consent is valid during the dates and for the duration of the registered season. I willingly provide this authorization to ensure prompt medical treatment under emergency circumstances, safeguarding the life and well-being of the named minor child when I am not present.
Signature*

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Date*

MonthDayYear
Date
Payment Options for $119*
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