Soccer and Agility Clinic Signup

Soccer & Agility Clinic
Student Name

First NameLast Name
Age
Grade
T-shirt Size
Enter T-shirt size, specify if child's or adult's
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone Number
Enter parent/guardian phone number
Parent/Guardian Email Address
example@example.com
Emergency Contact (if different from Parent/Guardian)

First NameLast Name
Allergies/Medical Conditions
Please type any allergies, medical conditions, or special considerations we should be aware of.
Athletic Release and Liability Waiver.

I give permission for my child to participate in the Points 2 Success youth athletic program. I understand that athletic activities involve inherent risks, and I release Points 2 Success, its staff, volunteers, and affiliates from liability for injuries or damages except in cases of gross negligence or willful misconduct. I authorize program staff to seek medical care in the event of an emergency.
Media Release
Electronic Signature
By typing my name below, I acknowledge that this serves as my legal signature and that I have read and agree to the releases above.
First Name* Last Name*
Date

MonthDayYear
Date
Should be Empty:

Soccer & Agility Clinic