Program Information
Winter '10/'11:	Please choose a WINTER Program Abhay's Birthday Party
Spring '11:	Please Choose a SPRING Program
Summer '11: Adult Futsal	Please Choose a SUMMER Program 6 Week Adult co-ed Futsal @ the Santa Clara Community Church $120
Discount:	Registration Discount Available (Only 1 per player) Before November 19th - $25 Discount Team Discount (5 players or more) - $25 Discount
Player Information
First Name:
Last Name:
Gender:	Please Choose Male Female
Date of Birth:
Age:
Grade:
Mailing Address:
Free T-Shirt Size:	Please Choose Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large
Soccer Playing Information
Age Group:	Please Choose U6 U8 U10 U12 U14
Level of Play:	Please Choose Never Played Before Recreational Class 3 Class 1
League/Team:
Parent / Guardian Information
Parent Name:
Parent E-mail:
Parent Phone:
Emergency Contact Information
Emergency Contact:
Emergency Phone:
Insurance Company:
Policy Number:
Allergies:
Other Information
Please include friend or teammate perference or other pertinent info:
Program Recognition
How did you hear about our programs?	Please Choose Previous Attendee Email Flyer Recommendation Website
Participation Agreement / Waiver of Liability
I certify that my child is in excellent physical health, and may participate in strenuous and hazardous physical activities, including the soccer to be played under the direction of the Planet Futsal.  I certify that there are no physical limits to my child’s participation.  I understand that accidents and injuries can arise from participation; knowing the risks, nevertheless, I hereby agree to assume those risks on behalf of the above named Minor and to release and to hold harmless all of the representatives of Planet Futsal.  Permission is granted for my child to receive emergency medical treatment if needed. In consideration of participation in the program offered above, I, the undersigned, as the parent/guardian of the Minor named above, agree to indemnify and hold Planet Futsal harmless and hereby waive, release and discharge any and all claims for damage, for death, personal injury, bodily injury or property damage which I and/or the Minor may have or which hereinafter may accrue to me and/or the Minor against Planet Futsal and may rise out of negligence or carelessness on the part of the persons mentioned above.  For players on soccer teams, my child has his/her coach’s permission to participate in the Planet Futsal training program. I agree to allow use of photography and videography of my child for publicity. It is understood and agreed that this waiver, release and assumption of risks has been freely entered into and is to be binding on my heirs and assigns.  I represent that I am a parent/guardian of the Minor named above and I agree that the grant and release contained therein binds me and the Minor to all its terms.
Participation Agreement:	Please Choose I Agree to Waiver I Disagree to Waiver