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Registration: Seniors Champion Soccer Program
First Name
Last Name
Email
Date Of Birth
Best Phone Number
Street Address
Street Address Line 2
City
Region/State
Postal / Zip code
Country
Emergency Contact Name & Relation
Phone
Doctor's Name
Phone
In my full knowledge and capacity, I hereby declare that I give my express and full permission to let myself be treated by a qualified medical physician in any circumstance that such attendance be so required to perform all or any immediate medical check-up or treatment.
I am fully aware that the Seniors Soccer Program and its sports activity may cause accidental injury to my persona. I assume any and all possible risk that may cause injury, illness, or death arising to such activity. I hereby declare that I waive my right to pursue any and all claims against Upright City, Corp and all associated partners, sponsors, and team members of the Seniors Soccer Program.
I agree to the terms & conditions
Your Signature
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