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2008 SOCCER TOUR and INTERNATIONAL SOCCER
CUP
ONLINE REGISTRATION FORM
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* Required Field
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*
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Child's name:
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*
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Address:
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City:
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*
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Zip Code:
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*
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State:
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*
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Male:
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Female:
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Date of Birth:
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*
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Parent/Guardian Name:
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*
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*
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Home Phone #:
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Emergency #:
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*
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Cell Phone #:
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*
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Email:
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Medical Conditions:
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*
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Current Team, Age Group, Position, Ranking
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Current Coach, Email, Phone Number
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Health Insurance, Policy Number and Phone
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*
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If you were given a code, please type it in
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SOCCER IS A PHYSICAL SPORT WHICH MAY RESULT IN INJURIES. BY YOUR SIGNATURE YOU AGREE TO
ALLOW YOUR CHILD TO PARTICIPATE IN THIS PROGRAM. BRAZILIAN SOCCER ACADEMY, ITS AGENTS &
EMPLOYEES & OFFICERS ARE RELEASED AND DISCHARGED FROM ALL CLAIMS, DEMANDS, ACTIONS,
JUDGMENTS WHICH THE UNDERSIGNED’S HEIR EXECUTORS, ADMINISTRATORS OR ASSIGNEES MAY HAVE
OR CLAIM AGAINST SOCCER CAMP BRAZIL, FOR ALL PERSONAL INJURIES KNOWN OR UNKNOWN AND
INJURIES TO PROPERTY REAL OR PERSONAL, CAUSED BY OR ARISING OUT OF THE AFOREMENTIONED
SPORTS ACTIVITIES OR ANY OTHER ACTIVITIES WHICH ARE INCIDENTAL OR NECESSARY THERETO. THE
UNDERSIGNED AUTHORIZES SOCCER CAMP BRAZIL, ITS EMPLOYEES AND OFFICERS TO ARRANGE FOR
ANY EMERGENCY MEDICAL CARE OF TREATMENT FOR THE ENROLLED CHILD WHICH MAY BE REQUIRED AS
A RESULT OF PARTICIPATING IN THE AFOREMENTIONED ACTIVITIES AND AGREE TO HOLD THE CAMP
EMPLOYEES, OFFICERS, FREE AND HARMLESS FOR ANY CLAIMS., DEMANDS OR SUITS FOR ANY INJURY OR
COMPLICATIONS WHATEVER WHICH MAY RESULT FROM SUCH TREATMENT. THE UNDERSIGNED, HAS READ
THIS RELEASE, UNDERSTANDS ITS TERMS AND EXECUTES IT VOLUNTARILY & WITH FULL KNOWLEDGE OF
ITS SIGNIFICANCE.
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*
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By checking this box, you agree with the conditions above.
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Questions, comments, or feedback:
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In order to process this application form, we must receive deposit within 10 days after
submitting this form. Please send deposit of $500 for Brazil Soccer Tour or $200 for Brazil
International Cup in the form of check or money order payable to the Brazilian Soccer
Academy, PO Box 93, Germantown, MD 20875.
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