Registration

Registration: Seniors Champion Soccer Program

First Name

Last Name

Date Of Birth

Best Phone Number

Street Address

Street Address Line 2

City

Region/State

Postal / Zip code

Emergency Contact Name & Relation

Phone

Doctor's Name

Phone

In my full knowledge and capacity, I hereby declare that I give my express and full permission to let myself be treated by a qualified medical physician in any circumstance that such attendance be so required to perform all or any immediate medical check-up or treatment.

I am fully aware that the Seniors Soccer Program and its sports activity may cause accidental injury to my persona. I assume any and all possible risk that may cause injury, illness, or death arising to such activity. I hereby declare that I waive my right to pursue any and all claims against Upright City, Corp and all associated partners, sponsors, and team members of the Seniors Soccer Program.

I agree to the terms & conditions

Your Signature

Select a date

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