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Venue

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PARENT'S DETAILS

First Name

Last Name

Phone

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PLAYER'S DETAILS

First Name

Last Name

Current Grade

What grade is your child currently completing?

Date of birth

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MEDICAL DETAILS

Medical Aid Society

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Medical Aid Number

Medical Aid Main Member

INDEMNITY & CONSENT

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I hereby consent to Coerver® South Africa and any of its commercial partners recording, retaining and reproducing my child’s image and voice by way of photographs, sound recordings and video. I further agree to the condition that, while every precaution will be taken for the safety and welfare of my child and for the care of his/her possessions, I will hold blameless and indemnify all persons, Coerver® South Africa and all other organisations associated with the activity, should any prejudice, loss, damage, illness or injury occur to my child during the above activity. This includes an indemnity against recovery of costs resulting from damage, loss and/or medical conditions or hospitalisation, unless such loss is caused by the negligence, wilfulness or deliberate act of Coerver® South Africa or one or more of its employees. I furthermore appoint the Coerver® South Africa staff supervising the activity to act in loco parentis in respect of my child should the need therefore arise.

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The World’s #1 Soccer Skills Teaching Method