EmailMe Form - Pipeline TOPSoccer Program

PLAYER'S LEGAL NAME *

First Last

Nickname?

GENDER *

Female

Male

DATE OF BIRTH *

MM / DD / YYYY

AGES: Program is for those 5 years old and up.

SHIRT SIZE *

PARENTS/GUARDIANS

PARENT/GUARDIAN #1 *

First Last

EMAIL #1 *

RETYPE EMAIL #1

TELEPHONE #1 *

ADDRESS #1 *

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

PARENT/GUARDIAN #2

First Last

EMAIL #2

RETYPE EMAIL #2

TELEPHONE #2

ADDRESS #2 (if different)

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

WAIVER

On behalf of my child, I accept and assume any and all risks associated with his/her attendance and participation in any and all Pipeline Soccer Club programs and activities. I understand that my child should not participate if he/she is not healthy. I understand that my child must abide by all rules and the instructions of staff. I understand that my presence is required at all sessions my son/daughter is in attendance so that I can care for him/her if injured or if he/she needs to use the rest room facilities. Permission is hereby granted for photographs and/or videos to be taken of my child at the sessions for use by Pipeline Soccer Club in their marketing or promotional materials. Knowing these facts, and in consideration of your accepting my child's participation in the program, I, or anyone acting on my child's behalf, agree that Pipeline Soccer Club and/or Pipeline Soccer Club staff are NOT responsible for accidents, injuries, and/or medical or dental expenses arising from my child's participation in the program. In accordance with this agreement, I promise not to sue, and I release Pipeline Soccer Club and anyone working on their behalf from all claims of liability or expenses of any kind relating to my child's participation in activities. *

BY CHECKING THIS BOX, I ACCEPT AND UNDERSTAND THE ABOVE WAIVER.