Registration Form
Participant #1 First and Last Name *
Your answer
Participant #1 Date of Birth *
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DD
/
YYYY
Gender *
Parent/Guardian First and Last Name *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Address *
Your answer
Participant #2 First and Last Name
Your answer
Participant #2 Date of Birth
MM
/
DD
/
YYYY
Participant #2 Gender
Medical Information: Does any participant listed have special needs, medical conditions or allergies?
Your answer
Who referred you to TBSA?
Name of the person who referred you
*Name must be listed here to qualify for the referral bonus
Your answer
By signing this form, I fully understand as the legal guardian of the above mentioned minor(s), that I release, waive, and forever discharge Triple Balance Soccer Academy and all of its employees and volunteers from liability from any and all claims resulting in personal injury, accidents or illnesses that may occur due to participants in this program *
I give permission to Triple Balance Soccer Academy representatives to take and use photographs and or digital images of my child for use in news releases and/or promotional material. I authorize use of these images without compensation *
Method of Payment *
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