Pro Soccer Kicks Registration Form
$100 per player ($80 for a sibling)
Make Checks Payable to:
Pro Soccer Kicks
29270 172 Avenue
Long Grove, IA 52756
http://www.prosoccerkicks.com
Participant Information
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First Name
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Last Name
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Sex
M
F
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Age as of July 18, 2011:
7
8
9
10
11
12
13
14
15
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T-shirt size:
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult Extra Large
Adult Primary Contact
*
Relationship to Participant:
Mother
Father
Guardian
Other
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First Name
*
Last Name
*
Address 1
Address 2
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City
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State
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Zip
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Phone
Alternate Phone
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Email Address
Waiver
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I agree not to hold the Scott County Department of Recreation and Parks, Clinton County Department of Recreation and Parks, DeWitt Park and Recreation, City of DeWitt, Pro Soccer Kicks, volunteers or any individual connected there with responsibility for any injury received by my child/ward as a result of participating in this tournament and/or camp and will hold them harmless from any damages whatsoever as a result of any injury. I understand that there is no applicable insurance through the program in the event my child/ward is injured.
Agree
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I grant my permission, in my absence, to the manager or supervisor of my child/ward to authorize medical treatment in case of any emergencies. I understand that emergency care would be provided for my child even if I do not grant medical treatment.
Grant
Do Not Grant
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Players First Name:
*
Players Last Name:
*
Parents Signatures:
*
Parent Emergency Contact #:
*
3rd Party Emergency Contact #:
*
Date Signed:
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Parents Email Address:
*
Indicates Response Required
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