EVENT REGISTRATION
*Name/ Nombre:
*Mailing Address / Domicilio:
*City / Cuidad:
*State / Estado:
*Zip Code / Codigo Postal:
*Telephone / Telefono:
*Email:
Birthdate: MM/DD/YYYY
*Gender / Genero:
PARENT/GUARDIAN INFORMATION
Parent Name/Nombre:

Recognizing the possibility of physical injury or any unforeseen events associated with soccer and in consideration for South Valley Chivas Academy and its affiliates, I hereby release, discharge and/or otherwise indemnify the South Valley Chivas Academy, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the clinic, against any claim by or on behalf of the registrant’s participation in the free clinic or being transported to or from the same, which transportation I hereby authorize. I am acknowledging that that my child is healthy and physically capable of participating in free clinic and all its activities