Curt Onalfo Soccer
Spring Break Program

Registration & Waiver Form

Parents or Guardian: Please complete this application, print it and mail it with your payment to the address below. A parent or guardian MUST SIGN each application before it will be accepted. Please make sure to circle the package number and letter your child will attend. We will confirm your participation in the winter program via email upon receipt of your signed waiver form and payment.

The Sessions Listed Below are Currently Available for Registration
Session	Type	Location	Dates	Times	Cost

Space is limited to 75 participants per session and applications will be accepted on a “first come, first served” basis. Participants must bring ball, fluids and be dressed in appropriate soccer attire. Players must wear indoor soccer or tennis shoes that do not mark surface. (NO CLEATS or black soles.) No kicking balls against wall. We want to ensure our relationship with Sport & Health Clubs continues; therefore, exemplary behavior is required of all participants.

Soccer Club Affiliation (MYS, VYS, ASA, etc.)
League/Division/Team Name (required for travel players only)
Participant Name
Participant Gender ( select one)	Female Male
Address
City
State
Zip

Primary Parent/Guardian Info
First Name / Last Name
Home Phone (including area code)
Work Phone
Cell Phone
E-mail Address (Mandatory for Confirmation)
Second Parent/Guardian Info
First Name / Last Name
Home Phone (including area code)
Work Phone
E-mail Address (Leave blank if same as Primary Parent/Guardian E-mail address)

How did you hear about this program?
T-shirt Size	Child: Sm. Med. Lg. XL Adult: Sm. Med. Lg. XL

Age (as of today)

Date of Birth (mm/dd/yy)

Insurance Carrier
Policy Number
Medical Conditions We Should Be Aware Of
Emergency Contact and Phone Number if parent or guardian is not available (not your cell phone)

Please note our Refund Policy: To guarantee your space, program sessions must be paid in full. Registration fee(s) will be refunded only upon written request and if cancellation is made at least two weeks before the first day of the session. There is a non-refundable $20 administrative fee subtracted from any refund.

If Paying By Credit Card: Please Circle Card Type: Visa MasterCard

Amt. To Be Charged: $________________ 16-Digit Acct. #: ________________________________

3-digit security code on back of card (after 16 digits): ____________ Exp. Date (mm/yy): _________

Please Print Name Of Cardholder: ____________________________________________________

Signature (Required for credit card): ________________________________________________

Please note a $4.00 processing fee will be added to all credit card payments.

Please mail payment and form to (please make payable to Curt Onalfo Soccer):

COS Spring Break Program
11707 Summerchase Circle #E
Reston, VA 20194

CONSENT, RELEASE AND AUTHORIZATION

I am the parent or guardian of the above named child (the “player”). I consent to the participation of the player in soccer-related programs operated by Curt Onalfo Soccer, Inc., including but not limited to training sessions, practices, games, and tournaments. I understand that the such programs are hazardous by their nature, and I assume all risk of injury or death arising from such activity, and accordingly I release, indemnify and agree to hold harmless Curt Onalfo Soccer, Inc., and the owner and operator in which the applicable program is located, and their respective directors, officers, employees, sponsors, counselors, and staff from any claim, suit, demand, or action arising in connection with the player’s participation in programs operated by Curt Onalfo Soccer, Inc. I further assume all responsibility for all transportation to and from such programs. If the player requires medical attention in the judgment of the supervisor of any program in which the player is participating, and the player’s parent or guardian or emergency contact cannot be reached after reasonable efforts to contact them (it being understood that no such efforts are required in case of emergency) the undersigned hereby authorizes such supervisor or a representative of Curt Onalfo Soccer, Inc., to obtain and authorize medical treatment for the player.
I HAVE CAREFULLY READ THE ABOVE CONSENT, RELEASE AND AUTHORIZATION AND FULLY UNDERSTAND ITS CONTENTS. I UNDERSTAND THIS IS A RELEASE OF LIABILITY AND I GIVE UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT VOLUNTARILY.

Signature: _______________________________________________________________________
Relationship: __________________________________ Date: ______________________________