Nickname_______________________________       

DOB_________________                 Age on August 1, 2007 ________                 

Team Name___________________      Coach______________________

Address _____________________________City________ ZIP_______

Phone Number (c) ____________(h)_____________(alt)____________

Email Address ______________________________________________

Parent's Names _____________________________________________

I, as Parent/Guardian, authorize any first aid or emergency medical care that may become necessary for my child/ward while he/she is participating in the “Soccer Camp".  In consideration of the acceptance of my child/ward's entry into the session, I, my heirs, executors, administrators and personal representatives hereby discharge, waive and release  Juan Sastoque, Josema Bazan ,Riverplate Soccer Club, Andromeda SC, Soccer Studio,  partners, sponsors, coaches, agents, employees, family and facility owners  from any Liability, Claims, Damages or Lawsuits resulting from Personal or Physical injury to my child/ward.

I certify that my child is not a member of a North-Texas State Soccer Association. I am aware that if my child is a member of a NTSSA, I am required to have the coach of that team read and sign the non-recruiting statement available at www.NtxSoccer.org to be able to participate in any Riverplate, training, camp or skills event.

I have read and understand the above-mentioned disclaimer and medical release.