Soccer Heroes New York

2018 Summer Registration Form

Please fill out the registration form for each kid.
Any discounts will be applied.

Athlete’s Information

First Name: ________________________ Last Name: ________________________

Age: __________________________ Birthday: __________________________

Current School: __________________________ Grade Level: _________________

T-shirt size: __________________________

Does the athlete have any allergies, chronic illness, or medical conditions that would
limit high level activity? If yes, please indicate “yes” below and enter as much detail as
possible. Please note, Soccer Heroes NY reserves the right to turn away a athlete if we
feel physical activity of any sort would cause damage to the athlete’s health.

Yes ______ No______

Please explain below, or enter N/A if not applicable:

Is the athlete prescribed an inhaler? If yes, please explain any instructions.

Parent/Guardian Information
First Name: _______________________ Last Name: _______________________

Home Number: ______________________ Cell Number: _____________________

Email Address: ____________________________________________________

Emergency Contact Information

First Name: ________________________ Last Name: ________________________

Relationship: ________________________ Contact Number: ___________________

Alternate Number: ________________________

Payment:

Paid for season:

Age Group:

Paid with: CASH CREDIT CHECK

Amount Paid: ________________________

On Date: ________________________

Day registered for: _______________________

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities of Soccer
Heroes New York, during the selected session. In exchange for the acceptance of said
child’s candidacy by Soccer Heroes New York, I assume all risk and hazards incidental
to the conduct of the activities, and release, absolve and hold harmless Soccer Heroes
New York and all its respective officers, agents, and representatives from any and all
liability for injuries to said child arising out of travel to, participating in, or returning from
practices, exhibitions, parades or competitions conducted during the season.

There is a risk of being injured that is inherent in all sports activities, including soccer. In
case of injury to said child, I hereby waive all claims against Soccer Heroes New York
including all coaches and affiliates, all participants, sponsoring agencies, advertisers,
and, if applicable, owners and lessors of premises used to conduct the event.

Please also note, all images and videos taken during practices, tryouts, games, and any
other activity during the season in relation to Soccer Heroes New York are the property
of Soccer Heroes New York and can be used for any promotional consideration.

I hereby state that I have carefully read the above waiver. Acceptance and
understanding of this agreement are hereby acknowledged.

I have read and agree to the Informed Consent and Acknowledgement.

X___________________________________________

Program Policies and Terms

There is a no refund policy. If, for any reason, you need to cancel registration, valid
reasoning must be provided in order to receive a refund. Whether or not the refund will
be granted is up to the discretion of Soccer Heroes New York. Notification of non-
participation must be given to Soccer Heroes New York by email. Emails should be sent
to info@soccerheroesny.com.

SEASON PAYMENT INFORMATION:

Payment for the full program fee is deemed due and owing to Soccer Heroes New York
upon registration for the season. You child is not considered registered until payment is
provided. If a child decides to leave at any point once the season has already started,
the fee for the remainder of the season is forfeited, with no refund.

I have read and agree to the Program Policies and Terms.

X___________________________________________

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize Soccer Heroes
New York to call a qualified and licensed medical professional for the diagnosis and
treatment of the minor child, in the event of a medical emergency, which in the opinion
of the attending medical professional, requires immediate attention to prevent further
endangerment of the minor’s life, physical disfigurement, physical impairment, or other
undue pain, suffering or discomfort, if delayed.

A reasonable effort will be made to reach the parent/guardian, but I authorize

permission to Soccer Heroes New York to make a decision based on the
recommendation of the medical professional in order to help said child.

Permission is also granted to the medical professional and/or Soccer Heroes New York
Director/Coach/Team Parent to provide the needed emergency treatment prior to the
child’s admission to the medical facility.

Release authorized on the dates of the registered sessions.

This release is authorized and executed of my own free will, with the sole purpose of
authorizing medical treatment under emergency circumstances, for the protection of life
and limb of the named minor child, in my absence.

I have read and agree to the Medical Release and Authorization.

X___________________________________________