SAMPSON SOCCER, INC.

Participant Registration
and Liability Waiver

PROGRAM: _____________________________________________

Child’s Name: ____________________________________________

Parent’s Name(s): _________________________________________

Address: ________________________________________________

_______________________________________________________

Home Phone: ____________________________________________

Alternate Phone: __________________________________________

Child’s Age: _____________

E-mail address: __________________________________________

Amount Enclosed: ________________________________________

Check / Money Order: ________ Credit Card: ______
Make check payable to: SAMPSON SOCCER

Credit Card info:
Please charge my Visa____ MasterCard____ Discover_____ American Express_____

Card Number: ________________________

Expiration Date: ________________________

Liability Waiver
(i) My child, listed above, is in good physical health and has my permission to participate in all activities associated with this clinic run by Sampson Soccer, Inc.
(ii) Sampson Soccer, Inc. assumes no responsibility and will not be held liable for any accident resulting in medical, dental, or any other expenses, associated with participation in this clinic.
(iii) I attest that my child carries personal medical insurance coverage and I understand the risks involved in playing competitive soccer.

Parent Signature: _________________________ Date: __________________