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Complete Coaching 

Total Soccer Academy

    T.S.A. Summer Goalkeeper's Camps



 

Total Soccer Academy is owned and operated by Mike Gentry who holds US Soccer  National “C”, US Soccer Goalkeeper License, NSCAA Goalkeeper Diploma and Miramar College Goalkeeper Coach

858-215-1872

www.thetotalsocceracademy.com              

 

Participant Name:___________________________________          Age:____________

 
Phone #:___________________________________                   Experience:_________

 
Email:_____________________________________           

 

WAIVER OF LIABILITY AND DISCLAIMER

I agree to indemnify, defend, hold harmless and release Michael Gentry, Gentry’s Goalkeeping School or Total Soccer Academy its owners, officers, agents, representatives, and employees from any and all lawsuits, damages, claims, judgments, loss, liability, or  expenses arising out of (1) any death or personal injuries or property damage that I may sustain while using property or equipment owned by or under the control of Michael Gentry, Gentry’s Goalkeeping School or Total Soccer Academy while participating in any activity sponsored by Michael Gentry, Gentry’s Goalkeeping School or Total Soccer Academy (2) any death or injury which results or increases by any action taken to medically treat me. All of the terms above shall apply whether or not the alleged injury is caused by or arises out of any dangerous condition of property, or the alleged negligence or any acts or omissions of Michael Gentry, Gentry’s Goalkeeping School or Total Soccer Academy its owners, officers, agents, representatives or employees. I understand that I under take this event to try and improve my health, fitness and/or entertainment.

 


Participant Name signature or Guardian signature ___________________________________________________

 

EMERGENCY AUTHORIZATION

In the event of sudden illness, accident, or injury which may occur while said Participant is engaged in activity. I authorize Michael Gentry, Gentry’s Goalkeeping School or Total Soccer Academy its owners, officers, agents, representatives, or employees, to consent to any medical, dental, or surgical diagnosis or treatment and hospital care for the above mentioned Participant which is deemed advisable by and to be rendered by a licensed physician or surgeon, and agree to assume financial liability for these services.

 
Emergency Contact (Please Print Clearly): ____________________________________________

 

Emergency Phone #_____________________________________________

 

 Allergies/Medications____________________________________________________________________________________________­­­­­­­­­­­­­­­­­­­

 

 

Health Insurance Co. Name:_______________________________________________

 Todays Date: _____________