EmailMe Form - WAITING LIST - MLUSC Inclusive Soccer

How Many Children will you be registering? *

PARENTS INFORMATION

Parent / Guardians Full Name *

Parent / Guardians Cell Phone Number *

### - ### - ####

Parent / Guardians Email *

2nd Parent / Guardians Full Name

2nd Parent / Guardians Cell Phone Number

### - ### - ####

2nd Parent / Guardians Email

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

FIRST CHILDS INFO

#1: Childs First Name *

#1: Childs Last Name *

#1: Childs Date of Birth *

#1: Childs School Name

#1: Childs Fav Sport/ Activity

#1: Childs Shirt Size

SECOND CHILDS INFO

#2: Childs First Name

#2: Childs Last Name

#2: Childs Date of Birth

#2: Childs School Name

#2: Childs Fav Sport/ Activity

#2: Childs Shirt Size

THIRD CHILDS INFO

#3: Childs First Name

#3: Childs Last Name

#3: Childs Date of Birth

#3: Childs School Name

#3: Childs Fav Sport/ Activity

#3: Childs Shirt Size

INSURANCE

Primary Insurance Details
(your childs insurance carrier and policy number)

in case of an emergency we have info for the medical department

NEEDS / MEDICAL / ALLERGIES

Special Needs

Please let us know the Special Needs of your Child and what our coaches must be aware of.

Medical

If your child does not have any, please leave blank

Allergies

If your child does not have any, please leave blank

HOW DID YOU HEAR ABOUT US?

How did you hear about us

TERMS & CONDITIONS

I have read and agree to the Terms of Service *

Yes, I agree.

I give consent for my child to take part in the activity and consent to emergency treatment as necessary. I accept that the organizers and their employees are not under any liability whatsoever in respect of injury, loss or damage whilst on the course, other than imposed by law. I also allow MLUSC to take photos for advertising and promoting purposes only; if I do not want my child's photo to be taken I will email info@mlusc.com to let them know. I confirm that my personal insurance is correct and bears responsibility in case of accidents. I confirm that I am legally entitled to give this consent and understand all payments received are non-refundable.

Signature

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