Perkins Soccer Academy Registration

Parent first name

Parent last name

Email

Phone

Athlete 1 first name

Athlete 1 last name

Athlete 1 grade (for 2025-2026 school year)

Athlete 1 shirt size

Athlete 2 first name

Athlete 2 last name

Athlete 2 grade (for 2025-2026 school year)

Athlete 2 shirt size

Athlete 3 first name

Athlete 3 last name

Athlete 3 grade (for 2025-2026 school year)

Athlete 3 shirt size

EMERGENCY MEDICAL INFORMATIONAL AND RELEASE

In the event of an accident emergency requiring emergency medical treatment for my child during the 2025 Pirates Soccer Academy the coach, league administrators, and/or assistant coach of my child’s team has my permission to obtain any medical treatment they feel is necessary for my child.

In the event reasonable attempts to contact person(s) listed above are unsuccessful, I hereby give my consent for the administration of any treatments deemed necessary by my preferred physician and /or dentist. In the event the designated preferred physician is not available, I hereby give my consent for any licensed physician or dentist to administer treatment deemed necessary. This authorization does not cover major surgery unless medical options of the two other licensed physicians or dentists, concurring the necessity for such surgery.

My child is covered by medical insurance.

My child is NOT covered by medical insurance: I, the undersigned, will assume responsibility for any medical expenses he/she incurs during participation in the Perkins Pirates Soccer Academy

I HEREBY DESIRE THAT MY CHILD, WHICH IS IN GOOD PHYSICAL HEALTH, PARTICIPATE IN THE 2025 PIRATES SOCCER ACADEMY. BY THE EXECUTION OF THIS RELEASE, I ACKNOWLEDGE AND AGREE THAT ALL THE REQUIREMENTS, DIRECTIONS, SUPERVISION, AND STANDARDS SET BY THE DIRECTORS OF THIS PROGRAM SHALL BE ESTABLISHED FOR MY CHILD'S BENEFIT. I HEREBY VOLUNTARILY ASSUME ALL RISK OF ACCIDENT OR INJURY TO MY CHILD WHICH MAY ARISE FROM HIS PARTICIPATION IN THIS PROGRAM, HEREBY INTENDING TO RELEASE THE PERKINS SCHOOLS, THE PERKINS PIRATES SOCCER ACADEMY AND THE PERSONNEL ASSOCIATED WITH THIS PROGRAM FROM LIABILITY.

Signature

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List any physical impairments, medical conditions, or learning impairments the staff needs to be aware of?

List any Allergies

List any medications the staff should be aware of? (For example, needs inhaler.)

I (parent/guardian) have read Lindsay's Law.

The athletes being registered have read Lindsay's Law.

Product

1 Athlete$65

Product

2 Athletes$100

Product

3 Athletes$130