Brookhaven Town Soccer

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Player Online Waiver

TEAM INFORMATION

* High School Team:

* Level:

PLAYER INFORMATION

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* GRADE in September:

* CELL PHONE:

* Birthdate:

* Home Phone:

* e-mail:

PARENT/GUARDIAN #1

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Parent or Guardian Adult e-mail:

* CELL PHONE:

* Home Phone:

* Work Phone:

PARENT/GUARDIAN #2

First Name:

Last Name:

Street:

City:

State:

Zip Code:

* Parent or Guardian Adult e-mail:

CELL PHONE:

Home Phone:

Work Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact:

* Relationship to Player:

* Phone:

Insurance Carrier:

Policy #:

WAIVER INFORMATION

I hereby authorize and approve my son/daughter's participation in the TOWN OF BROOKHAVEN YOUTH SOCCER PROGRAM. I know of no physical conditions or illnesses which would interfere with or prevent their/my participation in this activity. I verify that the information listed on this registration is correct and give my permission for their/my participation.
The undersigned hereby assumes all risks in the performance of YOUTH SOCCER IN THE TOWN OF BROOKHAVEN and undertakes complete responsibility for all acts undertaken by the undersigned in connection with the event on the TOWN OF BROOKHAVEN PREMISES/PROPERTY located on the grounds of TOWN OF BROOKHAVEN FIELDS during the period of January 1, 2024 thru December 31, 2024. The undersigned further agrees to save harmless the TOWN OF BROOKHAVEN, it's officers, agents, servants, employees and enumerated volunteers, from any and all liability for any personal injuries or property damages suffered.
As a participant in the program organized and directed under the auspices of the Department of Parks, Recreation, Sports and Cultural Resources of the Town of Brookhaven, I understand that the Town of Brookhaven has not undertaken to provide any medical coverage through insurance or any other means for any injury I may suffer as a result of such participation and that I personally assume all risks of injury to myself and any medical costs related thereto. The undersigned further agrees to hold the TOWN OF BROOKHAVEN harmless from any claims made by any person for any loss, damage or injury resulting from or arising out of any acts or omissions of the undersigned or any other person acting on behalf of the undersigned, with regards to or in connection with the event.

I/we agree with the above ... *

* indicates required fields

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Player Online Waiver