Brazil Soccer USA
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Email *
Parent or Guardian *
Player Name *
Gender *
Street Address *
City *
State *
Zip Code *
Cell Phone *
Additional Phone
Birthdate *
Insurance Carrier
Policy #
I grant my child, named above, permission to participate in individual and/or group soccer lessons held by Brazil Soccer USA. I understand that these lessons are for soccer players, as such, my son/daughter is eligible to participate. I waive all claims of liability against Brazil Soccer USA and Gerhard Benthin, its directors, and employees,the eity of the event, or any other affiliated sponsoring body, corporate affiliated sporting body,corporate affiliate, or associate staff members. My son/daughter will participate in the program/lessons using the proper protective equipment, he/she does so at his/her own risk with my permission. As the parent or legal guardian of the above named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor Of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb or well being of my dependent. Brazil Soccer USA has the right to use any photos taken *
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