KBFC Pro Soccer Academy Registration Player Registration Form 1 Player Information 2 Participation Agreement 3 Billing Information Player's Name* First Last Gender*MFDate of Birth* MM DD YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home PhoneCell PhoneEmail* TERMS AND CONDITIONS In consideration of the acceptance of my child/ward’s membership in the Kingston-Belleville FC Pro Soccer Academy, I, the parent/guardian (for the participant under 18 years of age), agree as follows: I understand that my child/ward cannot play in any sanctioned soccer game until after this registration form has been validated and the registration data has been entered in The Kingston-Belleville FC Pro Soccer Academy computerized registration system. I have reviewed the participation agreement attached and my signature affixed hereto indicates my agreement with such participation agreement. I am aware of Kingston-Belleville FC Pro Soccer Academy and League bylaws, policies, rules and regulations and agree to abide by them and to be bound by them. I accept sole responsibility for my child/ward’s personal possessions and athletic equipment. I accept all liability for any damage to the playing equipment caused by my child/ward’s careless, negligent and/or improper handling. By signing and dating below, you agree that you are the parent or legal guardian of the player being registered and to be bound by this Legal Agreement even if you have not read the agreement Signature of Parent/Guardian* Date* MM DD YYYY Participant's agreement for those under 18 yrs By signing this document you will waive certain legal rights, PLEASE READ CAREFULLY.Name of Participant* First Last Age*Date of Birth* MM DD YYYY IN CONSIDERATION of allowing my minor child/ward to participate in the programs, activities and events of Kingston-Belleville FC Pro Soccer Academy, I ASSURE TO YOU THAT: I am the parent/guardian of the above named participant having full legal responsibility for decisions regarding the above named participant. I believe that my child/ward is physically, emotionally and mentally able to participate in the programs, activities and events of Kingston-Belleville FC Pro Soccer Academy. I hereby acknowledge that I am aware of the risks and hazards associated with or related to soccer. The risks and hazards include, but are not limited to injuries from: Executing strenuous and demanding physical techniques in soccer; Dry-land training including weights, running and massage; Grass, turf and other surfaces including bacterial infections and rashes; Falls to the ground due to uneven or irregular terrain or surfaces; Collisions with walls and soccer equipment; Failure to properly use any piece of equipment or from the mechanical failure of any piece of equipment; Extreme weather conditions which may result in heatstroke, sunstroke or hypothermia; Contact, colliding or being struck by other participants, spectators, equipment or vehicles; Vigorous physical exertion and strenuous cardiovascular workouts; Exerting and stretching various muscle groups; and Travel to and from competitive events and associated non-competitive events that are an integral part of the organization’s activities. Furthermore, I am aware that my child/ward may: Sustain injuries in soccer that can be severe, cause spinal cord injuries and even be fatal; Experience anxiety while challenging himself/herself during the activities, events and programs; Come into close contact with other participants, including the possibility of accidental and unexpected contact; Risk of injury is reduced if he/she follows all rules established for participation; and Risk of injury increases as he/she become fatigued. I UNDERSTAND AND AGREE, on behalf of myself, my heirs, assigns, personal representatives and next of kin that my signing of this document constitutes: I am registering my child/ward willingly and my child/ward is participating voluntarily in these activities, events and programs. I agree that there are risks in soccer as described above and my child/ward will be exposed to these risks and hazards. I agree to accept all these risks and hazards and be responsible for any injury or other loss that my minor child/ward might receive while participating in these events, activities and programs. If something happens to my child/ward, I release the Organizers of responsibility for any claims, demands, actions and costs that might arise out of my child/ward’s participation. I understand “Organizers” to mean: Kingston-Belleville FC Pro Soccer Academy and their directors, officers, members, employees, volunteers, officials, participants, clubs, agents, sponsors, owners/operators of facilities, and representatives. I ACKNOWLEDGE MAKING THIS AGREEMENT By signing and dating below, you agree that you are the parent or legal guardian of the player being registered and to be bound by this Legal Agreement even if you have not read the agreement.Name of Parent or Guardian* First Last Signature of Parent or Guardian* Date* MM DD YYYY Purchase Program EnrollmentSelect a ProgramKickstart ($ 150.00 CAD)KBFC Academy Main Camp $250 / week (before May 31st) $265 / week (after May 31st) *6 SessionsKBFC Academy MiniMites Camp $150 / week (before May 31st) $165 / week (after May 31st) *6 SessionsChoose a Session July 25 - July 29 August 2 - August 5 August 8 - August 12 August 15-August 19 August 22 - August 26 August 29- September 2 Choose a Session July 25 - July 29 August 2 - August 5 August 8 - August 12 August 15-August 19 August 22 - August 26 August 29- September 2 Total $ 0.00 CAD Billing InformationName of Payee* First Last Billing Email* Billing Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneThis field is for validation purposes and should be left unchanged.