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New England Sportscenter Futsal Player Registration
Derry New England SportsCenter Thursday Training Session 1 of 2024/25
1
Complete Form
2
Payment
3
Confirmation
Option:
--Select--
U6-U10 (5:30-6:30)
U11-U12 (6:30-7:30)
U13+ (7:30-8:30)
Price:
Description:
= Required Field
--Select Player--
GENDER
Please select...
Male
Female
CITY
STATE
--Select--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AB
BC
MB
NB
NF
NT
NS
NU
ON
PE
QC
SK
YT
DATE OF BIRTH
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AGE GROUP
('24-'25)
Please select...
U05 (2020)
U06 (2019)
U07 (2018)
U08 (2017)
U09 (2016)
U10 (2015)
U11 (2014)
U12 (2013)
U13 (2012)
U14 (2011)
U15 (2010)
U16 (2009)
Home Phone
Cell Phone
Grade
('24-'25)
:
--select--
1
2
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4
5
6
7
8
9
10
11
12
Pre-K
K
Emergency Contact
Emergency #
Comments
Approvals
I, the parent/guardian of the above named Registrant, in consideration of accepting the Registrant for their soccer and/or futsal programs and activities (collectively the “Programs”) and recognizing the risk of potentially significant physical injury occurring by participation in the Programs, including permanent disability or death, for myself and Registrant, do knowingly and freely assume all such risks, both known and unknown, and assume full responsibility for the Registrants participation in the Programs. Further, I, for myself and Registrant, and on behalf of our respective heirs, assigns, personal representatives and next of kin, do hereby release, indemnify and hold harmless Brazilian Art Soccer Training, FutsalNH, its affiliated organizations and sponsors, and each of their employees, volunteers, agents, other participants, hosts, sponsors, advertisers, and the owners of the premises upon which the Programs are held (collectively, the "Releases"), with respect to any and all injury, disability, death, or loss or damage to person or property incident to Registrants participation in the Programs, and/or being transported to or from the same, which transportation I hereby authorize, and whether arising from the negligence of the Releases or otherwise, to the fullest extent permitted by law. I hereby warrant and represent that the Registrant has received a physical examination by a physician and has been found physically capable of participating in the Programs with no reservations or restrictions. I, for myself and Registrant, do hereby consent to have a doctor of medicine or dentistry, a licensed nurse or emergency technician provide Registrant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY
I, the parent/guardian of the above named Registrant, in consideration for accepting the Registrant for their Soccer and/or Futsal programs and activities (collectively the “Programs”) hereby grants to FutsalNH and Brazilian Art Soccer Training, LLC, the right and permission, free from approval, review, or cost, to photograph, record, or otherwise capture the Registrant's likeness in participating in the programs for use in media, now or hereafter known, including, but not limited to pictures and video, to copyright the same in its own name, and which may be included in whole or in part for commercial or promotional use.
CONTACT INFORMATION
GUARDIAN #1
Same as player
STATE
--Select--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AB
BC
MB
NB
NF
NT
NS
NU
ON
PE
QC
SK
YT
ZIPCODE
1 of the 3 phone numbers below must be filled in
HOME
WORK
CELL
PREFERENCE
Home
Work
Cell
I would like to volunteer
Coach
Assist. Coach
Field Marshall
Referee
Team Manager
GUARDIAN #2 (optional)
Same as player
STATE
--Select--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AB
BC
MB
NB
NF
NT
NS
NU
ON
PE
QC
SK
YT
ZIPCODE
1 of the 3 phone numbers below must be filled in
HOME
WORK
CELL
PREFERENCE
Home
Work
Cell
I would like to volunteer
Coach
Assist. Coach
Field Marshall
Referee
Team Manager
Add Another Player
CONTINUE
Refund Policy
Thank you for registering for the Futsal Winter Training. You may cancel your registration before the registration deadline and receive a refund of your fees minus a $50 administrative fee.
Contact Info
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