If you’re interested in getting private lessons from us, please fill out the form below and we’ll get in touch with you as soon as we can! Player Information:Name:* First Last Age:*Birth Date:* MM slash DD slash YYYY Gender:* Male Female New Player? Yes No Parent/Guardian Information:Name:* First Last Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Emergency Contact Information:Name* First Last Relation to Player:* If applicable, list any medical problems(s)/physical limitation(s) the player has:Waiver:We, the registrant and the registrant’s legal parent or guardian, hereby agree and acknowledge the following: (1) We recognize the inherent risk of serious or permanent physical injury and possible death associated with youth soccer activities and games. In consideration for Coach Charles Lawrence accepting the youth player’s registration and participation in practices, we hereby release, discharge and/or otherwise indemnify and hold harmless Coach Charles Lawrence, his affiliated organizations and sponsors, volunteers, and associated personnel, including the owners of fields and facilities utilized for the practices, against any claim, lawsuit or written demand. (2) We consent to emergency medical care prescribed by a duly licensed Health Care Provider or Dentist. This care may be given under whatever conditions are necessary to preserve the registrant’s well-being and we hereby agree to be financially responsible for all costs associated with such treatment. (3) We consent to Coach Charles Lawrence taking photographs, video recordings, and/or sound recordings in documenting the soccer activities. We hereby grant Coach Charles Lawrence and his affiliates permission to use the negatives, prints, motion pictures, video/audio tapings, or any other reproduction of the same for educational and promotional purposes. We have read this release and waiver of liability and fully understand its terms. We understand that we waive substantial rights by signing this form. We agree to waive all such rights above including the right to file a legal action or assert a claim for personal or physical injury or death of any kind. We sign this release form freely of our own free will.Do you accept these terms?* Yes No You have to accept the terms to submit the form. Do you accept the terms?* Yes Type out your first and last name to "sign" this document:* Δ TO CONTACT US FOR MORE INFORMATION!Email : [email protected], phone (760)-672-5383, (760)-525-3648 2022-08-02
