Enrollment Application

If you are planning to enroll two children or more, submit this form for each child.

Parent Information

Parent First Name *

Parent Last Name *

Phone

Email *

Address *

Street Address

City

State

Postal Code

Palyer(s) Information

Number of Family Palyers *

Child Full Name *

Age *

Date of Birth *

Allergies *

2: Child Full Name *

2: Age *

2: Date of Birth *

2: Allergies *

3: Child Full Name *

3: Age *

3: Date of Birth

3: Allergies *

4: Child Full Name *

4: Age *

4: Date of Birth *

4: Allergies *

5: Child Full Name *

5: Age *

5: Date of Birth *

5: Allergies *

Emergency Contacts (Other Than Parent)

The following person will also be contacted and is authorized to pick up the child from the facility in case of illness, accident, or emergency, only if the custodian parent or legal guardian cannot be reached.

Emergency Contact

Emergency Contact's Phone

Medical Information

Doctor's Name

Doctor's Phone Number

Doctor's Address

Select Membership Plan *

BASIC

STANDARD

PREMIUM

Parental Waiver & Release of Liability

Parent / Legal Guardian Full Name *

Assumption Of Risk *

I understand that participation in soccer activities involves inherent risks, including but not limited to physical injury, collisions with other players, falls, weather conditions, and other potential hazards. I voluntarily allow my child to participate in all activities organized by Impact Soccer Academy and knowingly assume all risks involved.

Release Of Liability *

I, on behalf of myself and my child, hereby release, waive, and discharge Impact Soccer Academy, its owners, directors, coaches, employees, contractors, volunteers, and affiliates from any and all claims, demands, actions, injuries, damages, or losses arising out of or related to my child’s participation in soccer activities, except in cases of gross negligence or willful misconduct.

Insurance Disclosure *

I acknowledge that Impact Soccer Academy maintains Commercial General Liability Insurance. I understand that such insurance may not cover all injuries, losses, or damages, and that I am responsible for any medical or related expenses incurred by my child.

Medical Authorization *

In the event of an emergency, I authorize Impact Soccer Academy staff to obtain emergency medical treatment for my child, including calling 911. I agree to assume full financial responsibility for any medical treatment provided.

Financial Liability *

I agree with Refund Policy (see below) and the following: (1) my membership is valid for 12 months from today, (2) all payments are not refundable, and (3) early cancellation worth the last month's trainings payment with the 30-day cancellation notice.

Photo & Video Release

I grant permission to Impact Soccer Academy to use photographs and/or video recordings of my child for promotional purposes, including website, social media, and marketing materials, without compensation.

Electronic Signature *

I acknowledge and agree that my electronic signature below has the same legal effect and validity as my written signature and that this Agreement is valid.

Signature *

Clear

I consent to receive non-marketing text messages from Impact Soccer Academy, LLC about account updates, service alerts, and appointment reminders. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

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