Adult Information
*Required Fields

*Last Name
*First Name
M.I.
*Street Address
*City
Zip
*Day Phone
Eve. Phone
*Email
*Emergency Contact
*Emerg. Contact Phone
Relationship: Participant Parent Guardian Other
If other, please explain:

*Participant's Name
*Sex: Male Female
*Birth Date
*Age
Grade

KICKS 4 KIDS SOCCER LLC WAIVER

Permission and hold harmless agreement:
(Registration will not be processed without signature. Must be signed by participants or guardians of age 18 or older.)

I, the undersigned participant, parent, or guardian, do hereby agree to allow my child to participate and/or allow the individual(s) named herein to participate in the abovementioned activity(ies) and further agree to indemnify and hold harmless KICKS 4 KIDS Soccer LLC, its officers and employees individually and collectively from harm, from all losses, claims, suits, actions, payments, judgments, demands, expenses, attorney's fees; defense cost, or actions of any kind resulting from personal injury to any person, (including bodily injury and death) arisen out of negligent performance of the individual hereunder, except any injury or damages arising out of the sole negligence of the Kicks4 Kids Soccer LLC.  I give permission for Kicks 4 Kids Soccer staff to obtain any needed medical assistance in case of an emergency, illness or accident. I understand that any resulting expenses or charges are my responsibility and I will pay them immediately, either directly or through personal insurance. I/we will not hold the Kicks 4 Kids Soccer LLC responsible for accidents or injuries sustained in this program. Pursuant to state law, Kicks 4 Kids Soccer LLC is not liable for injury or damages to program participants unless caused by willful, malicious or grossly negligent conduct.

Digital Signature *
By typing your name in this box you are verifying you are approving the Kicks 4 Kids Soccer LLC Waiver. You must also download a WAIVER FORM, fill out, sign and mail to us asap. Your child can not participate until the waiver is received. Thank you.