Registration: U11

Player Details

First Name *

Last Name *

Date of Birth *

Does your child / ward have any allergies or medical conditions? *YesNo

If yes please list below:0 / 180

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Parent / Guardian Details

Name of Parent / Guardian *

Relationship to Player *

Street Address *

Apartment, suite, etc

City *

ZIP / Postal Code

Country

Parent / Guardian Email Address *

Phone Number *

Mobile Phone

Occupation

Employer

Parent / Guardian Details

If you wish to add a second parent/guardian to the application, please complete the section below.

Name of Parent / Guardian Two

Relationship to Player

Street Address

Apartment, suite, etc

City

ZIP / Postal Code

Country

Parent / Guardian Email Address

Phone Number

Mobile Phone

Occupation

Employer

In Case Of Emergency

Emergency Contact Name *

Emergency Contact Phone *

Weekly Attendance

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Waiver:

INDIVIDUAL PARENTAL WAIVER – RELEASE OF LIABILITY & INDEMNIFICATION By participation at KickStart Football Club Inc.’s (“KickStart”) football and tennis programs and by payment of the fees as confirmation, a player and guardian agrees to understand and accept the following disclaimer:

1. To release KickStart Football Club Inc. from all risks of personal injury or personal property damage which might be associated with participation and involvement in these programs. I further voluntarily remise, release and forever discharge the Directors of KickStart, its successors, assigns, officers and agents from any and all injuries, losses or damages of any kind whatsoever suffered by the player as a result of the voluntary use and participation in any facilities and activities provided through KickStart. I hereby certify that the player’s physical condition is at a sufficient level to enable them to use the participate in club activities safely. We agree to follow all instructions, rules and regulations of KickStart regarding use of any facilities while engaged in KickStart’s activities.

2. To understand that there are certain inherent risks and hazards involved in participating in athletic events that may result in injury or death to me or my child including, but not limited to those hazards associated with weather and playing conditions, equipment and other participants.

3. Further, in consideration of participation in the Club, we agree on behalf of myself and the player and my heirs and anyone else acting on my behalf to release, indemnify, and hold harmless, and covenant not to sue, KickStart and all of its members and/or agents, from all liability for any personal injury or personal property damage the player might sustain during practice, other workouts, or contests, whether supervised or on their own, and whether attributable to negligence, gross negligence, or recklessness on the part of such persons or entities.

I ACKNOWLEDGE THAT I HAVE READ AND THAT I UNDERSTAND EACH AND EVERY ONE OF THE PROVISIONS IN THIS WAIVER, RELEASE OF LIABILITY: *Yes

Waiver Signature *

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