Family Information

Parent Name

Street Address

Town / City

State

NJ NY PA MD DE CT VA

Zip

Home Phone

Daytime Phone

E-Mail

Family Doctor                         Doctor Phone

Player Information

Player Name

Age

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Gender

Male Female

Date of Birth

Current Team

Are you Goalkeeper:             Yes          No      

Positions Played

 PARENT / GUARDIAN CONSENT AND WAIVER

I hereby represent that the above information is true and accurate and the named applicant is in good health and has my permission to participate in the Merlin Soccer Academy . I acknowledge that soccer is a contact sport and that there is a risk of injury from participating in the camp and its related activities. I HEREBY WAIVE AND RELEASE Merlin Soccer Academy, Merlin Villagomez and its agents, servants and employees from any and liability and claims for damage. In the event of an emergency I hereby give permission to such Medical personnel as necessary to render treatment.

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Parent/Guardian Signature                                      Date

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