2024/2025 REGISTRATION FORM

Please enable JavaScript in your browser to complete this form.

First Name

Last Name

Gender

Date of Birth

Parents’ Names

Address

Address Line 1

City

State / Province / Region

Postal Code

Home #

Cell #

Health Card Number

Medications

Allergies

Injuries

Name and Phone # of Family Physician

Emergency Contact Name

Emergency Contact #

Terms & Condition

I hereby release and forever discharge Roberts Canada Soccer Academy, it's owner, authorized agents, employees and representatives from any and all causes of action, claims, damages, loss, or injuries of every nature and kind, howsoever arising, which I or the participant ever had, now has (have), or may hereafter have as a result of participation in this program. I authorize the provision of emergency medical services to the participant if deemed necessary by a qualified medical practitioner. I authorize Roberts Canada Soccer Academy to use photos or video excerpts of the participants, which may be used for advertising and/or instructional purposes. I certify that I am authorized to sign this release without the consent of any other person, as I am either the player registering and am 18 years of age or older, OR I am the parent/legal guardian of the player whom I am registering.

Parent’s Name

Signature

Clear Signature

Date

THERE IS NO REFUND AFTER REGISTRATION

Registration