7/30/2019 Roberts Elementary Indoor Soccer

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Medford Community Schools RobertsElementary School Indoor Soccer January

22nd to March 21st 2013**** no soccer during Feb Vac.REGISTRATION FORM

Name: _________________________ Phone ______________ D.O.B________Address: _____________ City: __________ School/Grade:_________

Parents Name: _____________________________ Phone __________________

Program Fee: $30.00 Check# _________ Cash ______(Make checks payable to Medford Community Schools. Checks may be mailed to Community Schools at 489 Winthrop Street or

checks or cash may be brought with you on the first day, January 22, 2010)

*In case of an emergency, please list two additional contacts ifthe parents cannot be contacted.Emergency Contact _____________________ Phone ________________ Relationship ____________ _

Emergency Contact _____________________ Phone ________________ Relationship ____________ _

Concerns/Allergies:

Hours: U8 to U 14 Tuesday,Wednesday,Thursday 6-9 pm

I/We _______________ parent /guardian of ___________________ ,minor, do hereby consent to his/her

participation in the Medford Community School Soccer Program and do forever release, acquit, discharge and

covenant to hold harmless the city of Medford and its successors, employees, servants and officers from anyandall actions, causes of actions, and claims, demands, damages, costs, on account of, or in any waygrowing out of,directly or indirectly, all known and unknown personal injuries or property damage which I/We may have now or

hereafter may have, including all claims or right of action for damages which said minor has or hereafter may

acquire, either before or after reaching majority resulting from his/her participation in the Medford Community

School Soccer Program and/or receiving medical attention as provided herein. Furthermore, I/We herby agree to

indemnify, reimburse or make good to the City of Medford or its successors, employees, agents, servants and

officers any loss or damage or costs, including attorney's fees the city or its representatives may incur ifanylitigation arises from said minors intentional, grossly negligent, or reckless acts or omissions while participating

in said programs. I/We understand that this program involves physical activity and hereby state that to my/our

knowledge such minor is in proper physical condition for participation in said program. I/We also agree to

provide such minor with all the proper and required equipment to participate in such programs.

In the event of an emergency requiring medical attention beyond first aid, I/WE hereby grant permission to aphysician or hospital personnel designated by the Medford Community Schools Program to attend to such minor.I have fully read and understand the terms of this release and waiver.

Signature ______________________________ Date _________________ _Must be signed by a parent/guar dian to part icipate

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