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Winter Clinic Registration
December 16th Session Only - $35
*
Indicates required field
Player Information
Player Name
*
First
Last
Gender
*
Boys
Girls
Birth Date
*
enter this format: MM/DD/YYYY
Street
*
City
*
Wilmington
Carolina Beach
Kure Beach
Wrightsville Beach
Leland
Shallotte
Southport
Other
Zip
*
28401
28403
28405
28409
28412
28428
28449
28451
28459
28461
28470
28479
other
Parent/Guardian Information
Parent Name
*
First
Last
Cell Phone
*
Email
*
Email will be used as primary communication. Make sure address is typed correctly.
Email #2
*
By clicking the Submit button below, you agree to have read the following Liability Waiver & Medical Consent.
You will then be directed to the online payment page to complete the registration process.
We/ I, as the parent/legal guardian of the player named above, do hereby declare our intent to allow this child to practice, play, and participate in all programs and activities associated with the Pleasure Island Soccer Association, including any related activities and transportation. We/ I hereby release and hold harmless from any and all liability; Pleasure Island Soccer Association, its coaches, sponsors, associated board members and personnel, officials, or any others associated with this organization against any claim by or on behalf of the player’s participation in this program
including any COVID-19 related sickness or bodily injury, and understand there is no medical insurance that applies. I/we agree that a
ny photos taken of players for player cards, team photos or action photos I give consent to PISA to use for website and purposes for exhibit & promoting PISA programs. I understand there are no refunds of registration fees if season is cancelled due to circumstances out of the organization's control, whether natural or by government or other entity's orders that prevent us from holding activities.
We/ I do hereby authorize Pleasure Island Soccer Association or any representatives including coaches, officials, or anyone associated with this organization, if after reasonable attempt has been made to reach the designated parent/guardian named above to consent, or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray, anesthetic, medical or surgical diagnosis or treatment or hospital care, to be rendered to the player under the general or special supervision and on the advise of any physician, dentist or surgeon duly licensed to practice, be indeed rendered to the Registrant.
By clicking the Submit button below, I agree to have read the Liability Waiver & Medical Consent above.
I understand my child is not registered to participate until payment is made immediately upon submitting this player form.
(you will be directed to payment page)
Submit Clinic Registration