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CHILD REGISTRATION FORM - 2019

To secure your child's spot in this year's soccer nights, please fill out the form below, PROVIDE CONSENT, AND SUBMIT.  A SEPERATE FORM IS REQUIRED FOR EACH CHILD.  STUDENTS MUST BE AGES 5 - 12 TO PARTICIPATE.


Child's Name *
Child's Name
Write "none" if your child has no allergies.
Please be specific. Write "none" if this does not apply to your child.
Parent/Guardian Name *
Parent/Guardian Name
Address *
Address
Primary Phone *
Primary Phone
Additional Phone
Additional Phone
optional
Please list the name and number for anyone else whom you wish to authorize to pick your child up from Soccer Nights.
Please list the name and number for anyone else whom you wish to authorize to pick your child up from Soccer Nights.
Parent Consent Section
Parent/Guardian Consent Form I, _____(name entered below)________, parent/legal guardian of_____(the child stated above)_______, age _(listed above), in consideration of the opportunity to participate in Soccer Nights conducted jointly by King’s Cross Church and Greensboro United Soccer during the week of July 15th, 2019 through July 18th, 2019 hereby agree and acknowledge as follows: 1. I understand that participation in Soccer Nights involves potential exposure to physical dangerous situations and may involve unavoidable risk of injury to participants or damage to property. 2. In consideration of the opportunity for my child to participate in Soccer Nights, I agree to hold harmless and indemnify King’s Cross Church, Greensboro United Soccer and their employees, volunteers, sponsors, agents, successors, heirs, estates, executors, administrators, and assigns from any and all claims, demands, actions, damages and liabilities whatsoever which may directly or indirectly result from or be related to any loss, damage or injury that may be sustained by my child or sustained by any other person or property, in connection with my child’s participation in Soccer Nights. 3. I further agree to release and forever discharge King’s Cross Church, Greensboro United Soccer, their employees, volunteers, sponsors, agents, successors, heirs, estates, executors, administrators and assigns, from all such claims, demands, actions, damages and liabilities whatsoever, which I may have, on behalf of my child whether foreseen or unforeseen, on account of my child’s participation in Soccer Nights. 4. This release and discharge shall be binding upon the successors, heirs, estates, executors, administrators, and assigns of the undersigned. 5. I certify that to the best of my knowledge, my child has no medical, psychological or physical conditions that could interfere with my safety in Soccer Nights activities and that I am willing to assume and bear the costs of all risks that may be created, directly or indirectly, by any such condition. 6. In the event of illness or injury, I hereby authorize representatives of King’s Cross Church and Greensboro United Soccer to act for me according to their best judgment in any emergency requiring immediate medical attention, and hereby grant the right to take appropriate action for my child’s health and safety and to obtain any necessary medical assistance. I understand that the directors & coaches of Soccer Nights, or anyone associated with either King’s Cross Church, Greensboro United Soccer, its trustees, agents, volunteers, sponsors and officers, will not assume responsibility for any medical or dental expenses incurred as a result of participation in this program, and those expenses shall be borne by me, as parent/guardian of my child, the registrant. 7. I give my consent to King’s Cross Church and Greensboro United Soccer to photograph, film, and/or use a photographic or digital reproduction of my child, to identify my child by name and/or to quote or record statements made by my child, for any editorial, promotional, or advertising purposes. I waive any right to inspect or approve the finished version(s). King’s Cross Church and Greensboro United Soccer and those whom are authorized shall have the rights to reproduce, distribute, and display publicly, including on the Internet— photographs, film, videotape, statements, and quotes covered by this release, and to prepare derivative works. I understand that King’s Cross Church and Greensboro United Soccer is not responsible for unauthorized duplication or use by third parties. 8. I acknowledge that I have read and fully understand this Agreement and Consent Form, and the attached Regulations, and that I have signed voluntarily on the Soccer Nights registration form.
Parent/guardian consent *
In order to give your consent, check the box below stating that you agree to the above statements. Your child cannot participate in Soccer Nights
Digital Signature *
Digital Signature
Please restate your first & last name to confirm your parental consent to the above statements.