Registration Form

Spring Break 2010 Soccer Jam | March 29 - April 2, 2010 | Las Vegas, NV

Player Name First Last
Date of Birth / MM / DD YYYY
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Contact Phone - (###) - ### ####
Email
Favorite Position
Club Team
Referred By
Parent/Guardian Info First Last
Mother Father
Mobile Number - (###) - ### ####
Any known health problems?
I do hereby expressly assume all of the risks which attend the game of soccer and any other sports or related activities, including but not limited to physical contact and physical injuries. I agree to indemnify and hold members including but not limited to any adjoining facilities and LV Soccer Jam Camps from any and all claims, suits, or proceedings arising allegedly or in reality out of the acts of omission and participation of the undersigned in any or related activity. I also agree to all rules and regulations of LV Soccer Jam Camps Parent/Guardian Consent
I understand that as part of our child’s participation in LV Soccer Jam Camps, photos, videos, and quotations may be taken for use in publications and reports about the program. We further understand that members of the news media invited to cover the program may take photos, videos and quotations. We grant permission to use such materials for the promotion of the program. Media Consent
As the parent or legal guardian of the above player, I hereby give consent for emergency medical care prescribed by a duly licensed doctor of medicine or dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of this minor, named above. Medical Consent
By checking this box, you agree to use an electronic signature in lieu of a paper-based signature. You understand that electronic signatures, just like your signing a piece of paper, are legally binding in the United States and in other countries. You further agree not to electronically sign any form without first reading it and ensuring you have accurately filled out the form to the best of your knowledge. Electronic Signature Consent
Date / MM / DD YYYY