EmailMe Form - USC Initial Registration Form

PRACTICE LOCATION

Main Practice Location

PARENTS INFORMATION

Mothers Name

Fathers Name

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Cell Phone Number #1 *

### - ### - ####

Cell Phone Number #2

### - ### - ####

Email #1 *

Email #2

How many Children are you registering? *

1 child only

2 children

3 children

Would you (or another family member) want to be become a Volunteer Coach? *

Yes - I want to Volunteer

No - not this time

*You will be Trained, Fingerprinted and Screened by the City Prior to Coaching and your Child will Discounted/Waived

CHILD #1 INFORMATION

#1: Child's Full Name *

Date of Birth *

School Name *

School Grade *

Shirt Size *

CHILD #2 INFORMATION

#2: Child's Full Name

Date of Birth

School Name

School Grade

Shirt Size

CHILD #3 INFORMATION

#3: Child's Full Name

Date of Birth

School Name

School Grade

Shirt Size

INSURANCE INFORMATION

Primary Insurance Details
(your childs insurance carrier and policy number)

Medical Concerns

HOW DID YOU HEAR ABOUT US?

Let Us Know! *

This will help us in our outreach marketing

I have read and agree to the Terms of Service *

Yes, I agree.

Your child must be covered by a private insurance, you must provide us with proof of your child’s insurance coverage. I give consent for my child to take part in the activity and consent to emergency treatment as necessary. I accept that the organizers and their employees are not under any liability whatsoever in respect of injury, loss or damage whilst on the course, other than imposed by law. I also allow USC to take photos for advertising and promoting purposes only; if you do not want your childs photo to be taken please email unitedsoccerclub@gmail.com I confirm that my personal insurance is correct and bears responsibility in case of accidents. I confirm that I am legally entitled to give this consent and understand all payments received are non-refundable.

I Understand that All Fees are Non-Refundable *

Yes, I agree.

I understand that if I want to Cancel my subscription, I must text 305 614 6935 prior to the automation date to request cancelation. There will be a $15 Reg fee to Re-Signup once cancelled initially