Curt
Onalfo Soccer
2008 Winter Program
Registration & Waiver Form
|
Curt
Onalfo Soccer 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. |
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| Space is limited to 20 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. |
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| Soccer Club Affiliation (MYS, VYS, ASA, etc.) | |
| League/Division/Team Name (required for travel players only) | |
| Participant Name | |
| Participant Gender (circle 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 the winter 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 three weeks before the first day of the session. There is a non-refundable $30 administrative fee subtracted from any refund and a $30 administrative fee may apply for program changes/special requests. Injury policy: Due to the potentially dangerous nature of soccer, whch is a contact sport, we cannot refund any fee(s) due to player injury, whether as a result of soccer training or otherwise. We reserve the right to modify this policy at any time. |
| If Paying By Credit Card:
Please Circle Card Type: Visa MasterCard 3-digit security code on back
of card (after 16 digits): ____________ Exp. Date (mm/yy):
_________ 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):
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. Curt Onalfo Soccer 5717 Waters Edge Landing Ct. Burke, VA 22015 CONSENT, RELEASE AND AUTHORIZATION 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: ______________________________ |