Delima Soccer Providing Individual Coaching Education and Team Training

Registration Form

Team Tour
Trip Dates
Individual Training Camp	10 days 20 days 30 days
Other
Cruzeiro Esporte clube	Desportivo Brasil
Atletico Paranaense	Oscar Inn Soccer Academy

First Name:
Last Name:
Date of Birth:
Gender:

Phone Number:
Nationality:
Street Address:
Address Line 2:
City:
State:
Postal Code:
Country:
Contact Number: Cell:
E-mail Address:
Club Name:
Player Position:
Coach’s Name:*
Coach’s Phone:
Emergency Contact Name:
Coache's E-mail Address:
Briefly describe what you would like to get out of this trip?

I would like a	Trip T-shirt ($20) DSE Polo ($30)

Signature: Date:
ELECTRONIC SIGNATURE WILL BE EQUIVALENT AS TYPING YOUR COMPLETE NAME


MEDICAL RELEASE AND
HOLD HARMLESS AGREEMENT FOR PLAYERS / COACHES


Insurance Company:
Insurance Company Address:
Policy Number:
Policy Holder:
Relationship to player:
Emergency contact:
Emergency Phone Number:
Emergency E-mail:

We verify that the player/coach listed below has been checked by a licensed Physician and is physically able to participate in the DSE Soccer Training Programs. We agree to allow the player/coach to be treated by a licensed Physician while attending, if necessary, and to assume all costs related to such treatment. We authorize our insurance company to pay all benefits. Also, we authorize the disclosure of medical information to our insurance Company for the purpose of claim(s). Hold Harmless Agreement: We and our heirs hereby release DELIMA SOCCER ENTERPRISES, Inc., its employees, officers and agents from any Liability for damages to or loss of personal property, loss of money, sickness or death, etc., for which is not culpable, which might occur while the Player/coach is participating in the DELIMA SOCCER ENTERPRISES, Inc. Training Program(s). Signature of Player/Coach Date Signature of Parent or Legal Guardian Date ELECTRONIC SIGNATURE WILL BE EQUIVALENT AS TYPING YOUR COMPLETE NAME ** Please type below this security code Exactly as shown. If you fail, You will have to start all over again: security Code:

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