Player's Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Parent's Name *

First Name

Last Name

Emergency Contact *

First Name

Last Name

Emergency Contact Phone # *

(###)

###

####

Waiver *

Medical: It is the responsibility of the player's parent/guardian to ensure that the player is healthy and fully able to participate in Imago Dei Soccer. Responsibility for medical insurance coverage rests with the player. I hereby give permission for the person herein described to participate in all Imago Dei Soccer activities. I understand that if a major medical problem arises, an attempt will be made to notify me by telephone. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected at the Imago Dei Soccer director's discretion to hospitalize, secure treatment, and order injections, anesthesia, or surgery for my player. In consideration for permitting (me/my players) to participate in Imago Dei Soccer, and with the intentions of binding (me/my player) and (my/our respective) heirs, and legal representatives, I hereby RELEASE & WAIVE any and all rights and claims for damages which (I/my player) may have against Imago Dei Soccer, Phillips Park, Ivey Redmon Sports Complex, High Point Athletic Complex, CCFC Youth, Community Bible Church, Life Community Church, Robert B Glenn High School, the Coaches, Players, Staff, Volunteers, Administration, and Representatives, for any and all property damage and personal injuries of any kind suffered by (me/my player) in connection with (me/my player's) participation in the Imago Dei Soccer, except for those arising out of the willing misconduct, gross neglect, or intentional torts of the above parties.

Yes

Promotion Waiver *

I agree to allow Imago Dei Soccer to use pictures & videos from this program for promotional purposes.

Yes

No