Name: ______________________________________    [  ] Male    [  ] Female

Address: _______________________________________ City:________________________State:______ Zip:__________

Home phone:___________________________ Email address:_________________________________________________

Age in June: ______________ School:_______________________________________ Grade in September:______________

Father's name: ______________________________ Work phone_____________________Cell:________________________

Mother's name: ______________________________ Work phone:____________________Cell: _______________________

Medical Ins Co: ____________________________________________ Policy #:___________________________________

Any allergies?:  _______________________________________________________________________________________

Medical conditions?: ___________________________________________________________________________________

Room/Teammate: _________________________________________________ T-shirt:   youth/adult    S   M   L   XL   XXL

How did you hear about us?:_____________________________________________ Send __________ additional brochures

  Day Camp (check all applicable boxes)

  Residential Camp (check all applicable boxes)

WAIVER AND RELEASE OF LIABILITY
Notice to Parent or Guardian: Do not sign this agreement before you read it. I acknowledge that my child will not be permitted to attend the Malibu Soccer Academy if I do not agree to the terms of this waiver.
I would like my child/children to attend the Malibu Soccer Academy . I acknowledge that staying at the Malibu Soccer Academy and participation in activities there can be INHERENTLY DANGEROUS ACTIVITIES which involve risk of injury. I acknowledge that my child may sustain injuries. On behalf of my child, I EXPRESSLY ASSUME ALL KNOWN OR UNKNOWN RISKS involved in such activities and ALLOW MY CHILD TO PARTICIPATE. I acknowledge that due to the nature of attending a soccer camp that accidents can and do occur even if the utmost care and safety is exercised. Nevertheless, I hereby EXPRESSLY WAIVE, RELEASE, AND FOREVER DISCHARGE the Malibu Soccer Academy, the owner of the camp, it's Independent Contractors, Instructors, Counselors, Employees, Sponsors and affiliates whosoever from ANY AND ALL LIABILITY, CLAIM, LOSS, DAMAGE, COST, OR EXPENSE arising from, or attributable in any way to, ANY NEGLIGENT ACT OR OMISSION on the part of any such person or the Malibu Soccer Academy. I acknowledge that I have carefully read this waiver and release and FULLY UNDERSTAND that it is a RELEASE OF LIABILITY. I also acknowledge that I AM WAIVING ANY AND ALL RIGHTS that I may have to bring a lawsuit in which I could assert a claim on behalf of my child against the Malibu Soccer Academy and all the other persons mentioned above for ANY INJURIES OR DAMAGES CAUSED BY THE NEGLIGENCE OF THE AFOREMENTIONED PARTIES.

X___________________________________________________________________       ________/_________/___________
                                          Parent or Guardian signature                                                          date