(Please Print)
Player Name _____________________________________________ |
Age
______ |
Birthdate
__________ |
| Address
___________________________________________ |
| City
__________________________________ |
State
_____ |
ZipCode
___________ |
| Home
Phone (Area Code & Number) ___________________ |
Business
Phone (Area Code & Number) ___________________ |
| Position:(check one) Field Player Goalkeeper
|
Grade
Entering: |
Gender:(check one)
Male Female |
| Email
Address (if available)
________________________________________________________________ |
| Emergency
Contact ______________________________________________________________ |
| Phone
(Area Code & Number) _______________________________ |
| Please
check the camp that you are registering for:
|
| On behalf of myself and my
child or ward, (“Applicant”) and on behalf of our respective heirs, assigns and
personal representative, I hereby agree not to sue and I fully and forever release, waive
and discharge the MidWest Soccer Academy, State of Missouri and the affiliates of either
or both of them and all their respective employees, officers, directors, agents and
volunteers (the “Releasees”) from and against all liabilities, claims, damages,
costs or expenses for personal injury, including death and/or property damage, which I or
the Applicant may sustain and which are or may be caused by the act or omission of the
Applicant, his fellow player, or any of the Releasees. I agree to indemnify the Releases
from any personal injury or property damage caused by the negligent or intentional act of
Applicant while on or about MidWest Soccer Academy premises or while participating in any
MidWest Soccer Academy activity.I acknowledge and agree that preparation for and
participating in the camp are dangerous and involve the risk of serious injury, including
death, and/or damage to property, and I hereby assume full responsibility for any risk of
such personal injury, including death, and damage to property. I warrant that the Applicant is in good health and has no physical
condition that would prevent his/her preparation for or participation in the camp.
I agree that you may photograph and/or videotape my
child during camp and that you retain the rights to use these visual images in any manner
you wish without compensation to my child.
This release is intended to be as broad and inclusive as
permitted by law, and if any portion thereof is held invalid the balance shall continue in
full legal force and effect.
I have read and fully understand the above Release.
|
Signed:
___________________________________________ Date: ________________
(Parent or Legal Guardian) |
Please print this form, fill it out and return it
with payment to:
MidWest Soccer Academy
5247 Fyler
St. Louis, MO 63139All payment is expected along with the application, except
for the Future Pros and Dream Week. A deposit of $75.00 is due
with application with the balance due no later than two weeks prior to camp week.
Early Drop Off/Late Pick Up - $5.00 per hour; earliest drop off 8:00 a.m.; latest pick
up 5:00 p.m. MUST make advanced
reservations.
For questions or information
Call 314-781-8493 or email mwsa@mwsa.info |