2023 Eagle Soccer School Registration

Camper First Name *

Camper Last Name *

Date of Birth *

Gender *

Male
Female
Non-binary

Fall 2023 Grade Level *

If registering more than one player select Yes and enter their first and last names below. If not registering more than one, select No and continue to Parent/Guardian First Name.

Parent/Guardian Name *

First

Last

Email *

Phone *

Address *

Address Line 1

City

State

Zip Code

Emergency Contact *

First

Last

Emergency Contact Phone *

For more information,
please feel free to contact camp directors:

Erin Reed at 860-205-1374 or by emailing [email protected] or

Mike Caccomo at 860-670-0394 or by emailing [email protected]

Please complete the waiver and release below:

COVID-19

In consideration of being allowed to participate in any way in any program, event, or activity sponsored or authorized by Connecticut Junior Soccer Association, Inc. and/or any affiliated member, I the undersigned, acknowledge, appreciate, and agree that: I am aware there are risks to me of exposure to, directly or indirectly, arising out of, contributed to, by, or resulting from an outbreak of any and all communicable diseases, including but not limited to, the virus “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)”, which is responsible for Coronavirus Disease (COVID-19) and/or any mutation or variation thereof. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS THE CONNECTICUT JUNIOR SOCCCER ASSOCIATION, INC. AND ITS AFFILIATED MEMBERS, and their respective officers, officials, agents and/or employees, other participants, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct any program, event, or activity (RELEASEES), from any and all claims, demands, losses, and liability arising out of or related to any ILLNESS, INJURY, DISABILITY OR DEATH I may suffer, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. 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.

Parent Guardian Signature (by typing your name you agree to be bound by this waiver and release)

Medical Release

PARENT’S APPROVAL AND MEDICAL RELEASE Recognizing the possibility of physical injury associated with soccer and in consideration for the USSF/USYSA and its affiliates accepting the registrant for its soccer programs and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify the USSF/USYSA, its affiliated organizations and sponsors, their employees and associated personnel, including the owner of fields and facilities utilized for the Programs against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. My son/daughter has received a physical examination by a physician and has been found physically capable of participating in the Programs. I hereby give my consent to have an athletic trainer and/or doctor of medicine or dentistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of each assistance and/or treatment.

Parent Guardian Signature (by typing your name you agree to be bound by this waiver and release)

Date *

Health Insurance Company *

Group Number *

Policy Number *

Special Medical Concerns / Allergies

By checking box you have reviewed and agree with our cancellation and refund policy. *

Agree

Cancellation / Refund Policy

One Camper

Price: $ 100.00

Payment Info *

Card

Name on Card

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