Midwest Soccer Academy-Youth Leagues
Team Registration (winter classic)
Contact Info
Main Contact Address
Coach City
Day Phone State Zip
Evening Phone Email Address
Program Info
Team Name Gender
Grade/Age
please download form and send to Midwest Soccer Academy, 5247 Fyler, St. Louis, Mo. 63139. or submit
Payment Info
I understand that submission of this application does not guarantee my team will be accepted.
Card Type Credit card Number Expiration
Name on Card Security Code (3 digit No. on back of card)
* There is a 5% surcharge for all charge payments
Liability Waiver
AS A PARENT/GUARDIAN , I UNDERSTAND THAT THERE ARE RISKS OF INJURY WHEN 1 PARTICIPATES IN SPORTS AND
OTHER ACTIVITIES AT THIS FACILITY (MIDWEST SOCCER ACADEMY), I ALSO UNDERSTAND THAT MIDWEST SOCCER ACADEMY IS NOT ACCEPTING OR ASSUMING ANY DUTIES OR RESPONSIBLITIES WITH RESPECT TO MY CHILD’S OR ANY OTHER PARTY GUEST’ SAFETY THEREFORE IN CONSIDERATION OF THE PERMISSION EXTENDED TO ME TO ENTER THESE PREMISES, I RELEASE AND FOREVER DISCHARGE MIDWEST SOCCER ACADEMY, FROM ANY CLAIMS THAT I HAVE, OR MIGHT HAVE IN THE FUTURE HAVE ARISING OUT OF OR CONCERNING MY PRESENCE AT THIS FACILITY OR MY PARTICIPATION IN ANY ACTIVITY AT THIS FACILITY, AND I PROMISE TO IMDEMNIFY MIDWEST SOCCER ACADEMY AND HOLD IT HARMLESS FROM ANY CLAIMS AND RELATED DEFENSE COSTS, INCLUDING REASONABLE ATTORNEY FEES, ARISING OUT OF MY PRESENCE OR PARTICIPATION IN ANY ACTIVITIES AT THIS FACILITY. IN ADDITION, I HEREBY AUTHORIZE MIDWEST SOCCER ACADEMY AND IT’S RESIGNS TO UTILIZE AND ALL PHOTOGRAPHS, PICTURES, OR OTHER LIKENESS OF THE PARTIIPANTS THEY DEEM APPROPRIATE IN IT’S PROMOTIONAL MATERIALS.
