Soccer Event Registration for: PENN LEGACY FUTSAL ACADEMY

Player Information Parent Information
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone: (999-999-9999)
Gender: Male:   Female:
Date of Birth: (mm/dd/yyyy)
Current grade in school:
FUTSAL ACADEMY ($25):
Carefully Select Team Name
First Name:
Last Name:
If address is different than Player, please fill in address:
Address:
City:
State:
Zip:
Phone: (999-999-9999)
Cell Phone: If no cell phone, then enter n/a.
Email Address:
Confirm Email Address:
Please check this box - I wish to pay the above fees by credit card MasterCard or Visa Only
 
Credit Card Information
First Name
:
Last Name
:
Street Address
:
City
:
State
:
:
 
:
Expiration date
:
   
Emergency Information
Emergency Contact:
Emergency Phone:
Health Insurance Name:
Physician Name:
Physician Phone:
Health Insurance Policy #:
List any medical conditions or prohibitions player has (please include allergies) :

Parent’s/Guardian’s Consent

The player registrant named above has my permission to participate in the Penn Legacy/Hempfield Soccer Club (HSC) Futsal program. In consideration of Penn Legacy/HSC's acceptance of my enrollment, I, the player and we, the parents/guardians, individually and collectively, intending to be legally bound, hereby for ourselves and our heirs, executors and administrators waive and release the Penn Legacy/HSC, Futsal program, Nook Sports and facility owners, their agents and representatives, from any and all claims or rights to damages for injuries or losses suffered by me the player, directly or indirectly, in training for, or traveling to and from, or competing in or while attending any future Penn Legacy/HSC Futsal functions. I acknowledge that the registration and or registration fee does not include accident insurance coverage. I consent for medical treatment for my child in the event of an emergency.

EPYSA RELEASE STATEMENT

I, the parent/guardian of the registrant, a minor or adult registrant of legal age, agree that I and the registrant will abide by the rules of EPYSA and the Penn Legacy/Hempfield Soccer Club Futsal Camps, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer, and in consideration for the EPYSA and Penn Legacy/HSC Futsal Program accepting the registrant for its soccer programs and activities (the "Programs"). I hereby release, discharge and/or otherwise indemnify the EPYSA, and Penn Legacy/HSC Futsal Program and its affiliated organizations and sponsors, their employees and associated personnel, including owners of fields or facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrants participation in the Programs, and/or being transported to or from the same which transportation I hereby authorize.

By submitting this form online, I accept and acknowledge the consent and release information, and I have provided correct information for registration.

I/WE HAVE READ THE ABOVE.
My electronic signature (after the "s/" below) indicates my agreement with the statements set forth above and my consent to be bound.
Please enter your First and Last Name: *s/