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Online Soccer Registration

Participant Name  Date of Birth  Age 

Sex: M F Current Grade in 2019  Special Request Coach or one child, please)  

Parent Name  E-Mail Address

Address City State Zip

Phone Number: Home  Cell   Work  

I'm interested in Coaching Name  Email 

        Late Fee of $15.00 Will Apply to Registrations Received After Aug. 2nd, 2019
NO REGISTRATIONS WILL BE ACCEPTED AFTER August 23rd, 2019 at 5:00pm

Financial Assistance Program May Be Available

$25 - Payable to the City of Hickman   *NO SHIRT*

Soccer Shirts are

same as T-ball &

Coach Pitch Shirts

$35 - Payable to the City of Hickman   *INCLUDES SHIRT*

T-Shirt Size: (Check One)

Youth:  S (6/8)    M (10/12)     L (14/16)

Select here if you DO NOT give permission for your minor child/ward(s) picture(s) to be on the City of Hickman Facebook, Website and/or Newsletter.

 

 I have read the Parent/Athlete Concussion Information Sheet

 WAIVER AND RELEASE OF LIABILITY    

   

Please read this form carefully and be aware that in participating you will be waiving and releasing all claims for injuries that you or your minor child/ward might sustain arising out of this participation.

 

As a participant or parent/guardian of a participant, I recognize and acknowledge that there are certain risks of physical injury and agree to assume the full risk of any injuries, including death, damages or loss which I or my minor child/ward may sustain as a result of participating in any and all activities connected with or associated with this program. 

 

I agree to waive and relinquish all claims I or my minor child/ward may have against the City of Hickman and its officials, officers, agents, servants and employees as a result of participating.  I do hereby fully release and discharge the City of Hickman and its officials, officers, agents, servants, employees and volunteers from any and all claims from injuries, including death, damage or loss which I or my minor child/ward may have or which may incur or may accrue to me or my minor child/ward on account of my participation.

 

I further agree to indemnify and hold harmless and defend the City of Hickman and its officials, officers, agents, servants, employees and volunteers from any and all claims resulting from injuries, including death, damages and losses sustained by me or my minor child/ward and or arising out of connected with, or in any way associated with the activities of my participation.

In accordance with Nebraska Statute 71-9105 (2011), parents and coaches must review the provided items that address the following:

  1. The Signs and Symptoms of a Concussion;
  2. The Risks Posed by Sustaining a Concussion; and,
  3. The Actions an athlete should take in response to sustaining a concussion, including the notification of his or her coaches.

(More information is available at www.cdc.gov/concussion/HeadsUp/youth.html)

By signing this form I acknowledge that I have read and fully understand the above warning of Risk and Waiver and Release of All Claims and have received information in accordance with Nebraska Statute 71-9105 regarding concussions.

 

Parent/Guardian Electronic Signature (Required     Date 

 

 

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