SSA GAL/DPL ID Clinic Registration
Thank you for your interest in our GAL/DPL program! A parent or guardian is required to complete this form on behalf of the participant. Once this form is completed, you will be contacted by our program director with an update on available sessions.
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Player First Name *
Player Last Name *
Player DOB *
MM
/
DD
/
YYYY
Preferred position(s)
Current Club and Team *
Parent/Guardian First Name *
Parent/Guardian Last Name *
E-mail Address *
Phone Number (no spaces - 1234567890) *
General Waiver:                                                                          I, being the Parent/Guardian of the participant listed above, hereby give electronic approval to his/her participation in all related soccer activities. I recognize the possibility of serious injury to such player and assume all risks and hazards related to such participation. I hereby release, discharge, absolve, and indemnify and agree to defend and hold harmless, US SOCCER INC., US YOUTH SOCCER, USSSA, US CLUB SOCCER INC., COBB FUTBOL INC. (DBA Southern Soccer Academy), and it’s affiliates, sponsors, employees, coaches, representatives and agents from and with respect to any claim, cause of action, liability, expense or obligation arising in connection with, or related to, such player's participation in the soccer activities. *
Medical Release:                                                                        I hereby grant permission to the club's coaching staff, in my absence, to authorize and obtain medical care and treatment for the participant listed above from any licensed physicians, nurses or medical personnel to the extent deemed necessary by such physician, nurse or medical personnel and I assume full financial responsibility for said treatment. *
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