Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

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Second Parent Name

First Name

Last Name

Phone

(###)

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Emergency contact 1 (other than parents) *

First Name

Last Name

Emergency contact 2 (other than parents) *

(###)

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Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

T-shirt size *

Youth T-Shirt sizes

XS (5-6)

S (6-7)

M (8-10)

L (12-14)

Fall Program Soccer Fundamentals at East River Playground *

Soccer building block skills

Monday 4:00-5:30 pm (6 to 8 year olds) - $120

Payment options *

Venmo (@waltamirano)

Zelle (jouk.soccer@gmail.com)

How did you hear about us? *

Referral

Google Ad

Facebook

Instagram

Other

Release and Waiver of Liability *

By selecting agree below submitting this online form by hitting the “SUBMIT” button below, which constitutes my electronic signature, I acknowledge and agree as follows: 1. I permit my child to fully participate in the voluntary activities sponsored by Joük, LLC (the “Program” or “Joük”). 2. I acknowledge, agree and represent that I understand the nature of the activity and that my child is qualified, in good health and in proper physical condition to participate in such activity. I further agree and warrant that if at any time I believe conditions to be unsafe for my child to participate, I will immediately discontinue my child’s further participation in the activity. 3. I FULLY UNDERSTAND that: (a) ATHLETIC ACTIVITIES INVOLVE RISKS & DANGERS OF SERIOUS INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, & DEATH (“RISKS”); (b) these Risks may be reduced by particular rules, equipment, & personal discipline, however the risk of serious injury does still exist; (c) these Risks & dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the activity, the condition in which the activity takes place, or THE NEGLIGENCE OF THE “RELEASES” NAMED BELOW; (d) there may be OTHER RISKS AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time, and I KNOWINGLY, FREELY, AND FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES my child incur as a result of his or her participation in the activity. 4. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my child’s presence or participation, I will remove my child from participation and bring such to the attention of the nearest official immediately. 5. I, for myself and on behalf of my participating heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Joük, their officers, members, managers, officials, agents, and/or employees, coaches, directors, volunteers, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the events (“RELEASES), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASES OR OTHERWISE, to the fullest extent permitted by law. 6. I certify that I, as parent/guardian with legal responsibility for the minor participant, do consent & agree to his/her release as provided above of all the releasees, and for myself, my heirs, and next of kin, I release & agree to indemnity and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law. 7. I grant to the directors, assistant or assigned coaches of Joük to act as guardians/spokesman in granting permission for emergency treatment/hospitalization (including anesthesia) if necessary for my child enroute to or from the Program site, hospital or other medical facility. I understand that should a health emergency arise, I will be attempted to be notified but that if I cannot be reached by telephone, such medical treatment deemed necessary, by competent medical personnel is authorized. I hereby authorize, Joük to allow the reproduction, dissemination, and/or publication of my name and likeness for media coverage, public relations, or any other purpose which may involve the use of photographs, films, and/or video tape recording. This is to be done in conjunction with my participating in the Program, and I understand and agree that I may neither pay a fee to receive individual promotional consideration from my participation in this program, nor will I receive payment for the possible commercial use of my name or likeness.

Agree

Disagree

Electronic Signature Date *

MM

DD

YYYY