Player's Name
*
First Name
Last Name
Player's Gender
*
Male
Female
Player's Age
*
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
Player's Birth Date
*
MM
DD
YYYY
Current Team
*
Preferred Position
*
Forward
Winger
Center Mid
Outside Back
Center Back
Goalkeeper
What Would You Like to Work On (select all that apply)
*
What Day's Work For You? (select all that apply)
*
*Morning & Early afternoon are the best times. Late afternoon into the evening are usually booked up.
Number of Sessions
*
1
2
3
4
5
6
7
8
Parent's Name
*
First Name
Last Name
Phone Number
*
Primary Email
*
Secondary Email
*
Comments/Requests
Waiver
*
It is the responsibility of the player's parent/guardian to ensure that the player is healthy and fully able to participate in the 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 the Imago Dei Soccer, Wesleyan Christian Academy, Phillips Park, Ivey Redmon Sports Complex, High Point Athletic Complex, PTFC, PSA, KSA, the YMCA and all of their 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.
Media: I agree to allowing Imago Dei Soccer to use pictures & videos from this program for promotional purposes.
Cancellation Policy: Please cancel at least 24 hours before your scheduled session to avoid penalty. If a session is cancelled within 24 hours of the session, 50% of the cost is still due.
Special Waiver (COVID-19)
*
In consideration of being allowed to participate in any way in any Imago Dei Soccer related events and activities I, the undersigned participant and parent (or legal guardian) acknowledge, appreciate, and agree that:
By participating in Imago Dei Soccer related events and activities, there are certain risks to me arising from or related to possible exposure to communicable diseases including, but not limited to, the virus “severe acute respiratory syndrome coronavirus 2, which is responsible for the Coronavirus Disease (also known as COVID-19) and/or any mutation or variation thereof (collectively referred to as “Communicable Diseases”). I am fully aware of the hazards associated with such Communicable Diseases and knowingly and voluntarily assume full responsibility for any and all risk of personal injury, illness or other loss that I may sustain in connection with such Communicable Diseases.
I, for myself and for my minor child(ren) or ward(s), and on behalf of my/our heirs, assigns, beneficiaries, executors, administrators, personal representatives, and next of kin, HEREBY EXPRESSLY RELEASE, HOLD HARMLESS, AND FOREVER DISCHARGE IMAGO DEI SOCCER, MAI. and its officers, directors, officials, agents, representatives, employees, other participants, sponsors, advertisers, and, if applicable, owners and lessors of premises, Wesleyan Christian Academy, Phillips Park, Ivey Redmon Sports Complex, the Hartley YMCA, High Point Athletic Complex, PTFC, PSA, KSA upon which Imago Dei Soccer related events and activities take place (the “Released Parties”), from any and all claims, demands, suits, causes of action, losses, and liability of any kind whatsoever, whether in law or equity, arising out of or related to any ILLNESS, INJURY, DISABILITY, DEATH, OR OTHER DAMAGES incurred due to or in connection with any Communicable Diseases, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASED PARTIES OR OTHERWISE, to the fullest extent permitted by law.
I agree that this Agreement is intended to be as broad and inclusive as is permitted by the laws of the State of North Carolina, and if any portion hereof is held invalid, it is agreed that the remainder shall continue in full legal force and effect.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
