Langford Development Block
Registration form for ambitious U12-U14 players preparing for the upcoming season. Program details: Location: Centre Mountain Lellum, Langford, BC; Dates: Sunday, August 2 / Sunday, August 9 / Sunday, August 16 / Sunday, August 23; Time: 9:00 AM – 10:30 AM; Eligibility: Players born in 2013, 2014, or 2015 (U12-U14); Investment: $150 for all 4 sessions.
Player Information
Player Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age Group / Eligibility
*
Please Select
U12 (born 2015)
U13 (born 2014)
U14 (born 2013)
Tier
Please Select
tier 1
tier 2
tier 3
Shirt Size
Please Select
YS
YM
YL
AS
AM
AL
Parent/Guardian Information
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Information
Medical conditions or health concerns
Allergies and reactions
Waiver & Acknowledgements
Program Terms Acknowledgement
*
I have read and agree to the program terms and conditions
I understand attendance and conduct expectations
I understand eligibility and participation requirements
Liability Waiver Acknowledgement
*
I acknowledge participation is at my own risk
I release the program and organizers from liability for ordinary negligence
I understand injuries may occur during training and activities
Assumption of Risk
*
I understand football training includes physical contact and exertion
I accept the risks associated with outdoor activity and athletic instruction
I confirm my child may participate subject to these risks
Parent/Guardian Confirmation
*
I confirm I am the parent or legal guardian of the participant
I have reviewed the program details and eligibility requirements
I understand the information provided is accurate and complete
Parent/Guardian Signature Name
*
First Name
Last Name
Signature
*
Payment Information
If you opt for etransfer, please send the etransfer to kyledegelman19@gmail.com. Payment is required to secure your spot.
Payment method
*
Please Select
Card
Etransfer
My Products
*
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Development Block Registration
$150.00 CAD
$
150.00
CAD
Quantity
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