2020 Gold Star Soccer 1 on 1 Registration

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Parent's Full Name *

Player's Full Name *

Gender *

Date of Birth - MM/DD/YYYY *

Email Address *

Address *

City *

State *

Zip Code *

Phone Number - Cell *

Name of soccer club you last played for *

Name of soccer coach your son/daughter plays for *

Best time to contact you for consultation? *

morning

Afternoon

Evening

Required

T-Shirt Size *

Medical Release Form

I do hereby release and discharge Dillard Development Systems and associates with Gold Star Soccer for all accidents and medical or dental expenses incurred as a result of participation with Gold Star Soccer. The above named applicant is in good health, and has my permission to participate in the physical activities of the rigorous Gold Star Sports program. In the event of an emergency or injury/illness, I grant permission for the applicant to be given treatment by a medical professional. I will assume all responsibility for payment of any uninsured cost incurred. I hereby irrevocably authorize Gold Star Soccer to edit, publish, or distribute the photograph/Video for purposes of publicizing the Gold Star Soccer programs.

Gold Star Soccer will not be held liable for any injury. All players must have their own health insurance. By participating in the above program I understand that I am responsible for all payments and that all payments are non-refundable.

I have read and Understand the above? *

I will assume all responsibility. By completing the registration form I do hereby allow Gold Star Soccer to use all photos/videos taken during a Gold Star Soccer program/event. Photos/videos will be used for merchandise and promotional use.

Electronic Signature *

Date *

YYYY

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