Walnut Creek Surf Soccer Club

2019/20 WC Surf TopXI Registration

Registration Form

Player Information

Parent / Guardian Contact Information

Emergency Contact Information

Medical Insurance

Release of Liability

By submitting this form, I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of US Club Soccer, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for Walnut Creek Surf Soccer Club ("WCSSC") and TopXI Soccer School ("TopXI") accepting the registrant for its soccer program and activities, I hereby release, discharge and otherwise indemnify WCSSC, TopXI, and US Club Soccer, their affiliated organizations and others, their employees and associated personnel, including the owners of the fields and facilities utilized for the program against any claims by or on behalf of the registrant as a result of the registrant’s participation in the program and/or being transported to or from the game, which transportation I hereby authorize. Release / Waiver: As a parent/ legal guardian of the previously named player, I authorize Walnut Creek Surf Soccer Club to provide any medical attention to said player. In addition, I will not attempt to hold Walnut Creek Surf Soccer Club liable for any injury, which may occur during activities affiliated with WCSSC and/or TopXI Soccer School.

Program Selection and Payment

Select the program(s) your player would like to attend. Note, each additional player needs a unique registration form filled out.