Registration and Participation Waiver for private skills instruction provided by

Totaalvoetbal Concepts.

The undersigned has chosen the following option:

___ (#) Individual sessions at total cost of $ _____

___ (#) Small group sessions at a total cost of $_____

(Please make checks payable to Totaalvoetbal Concepts regardless of location)

Participant Name/Age ____________________________

Club/Position(s) _________________________________

Address _________________________________

Phone (hm/cell) _________________/_______________

Email _________________________________

Health issues _________________________________

I/we the undersigned hereby certify that I/we am/are the parent(s) or legal guardian(s) of the participant. I/we

further certify that the participant is mentally, emotionally and physically able to participate in any and all

anticipated activities related to private sports training. Additionally, I/we hereby give permission to the staff of

TotaalVoetbal Concepts to seek appropriate medical attention for the participant and for that medical attention to

be given in the event of accident, injury or illness. I/we will be responsible for any and all costs of medical attention

and treatment. I/we the undersigned for ourselves, our heirs, executors and administrators do hold harmless,

waive, release and forever discharge TotaalVoetbal Concepts of Illinois and its staff, officers, agents, employees,

contractors, representatives and successors and assign of and from all rights and claims for damages, injury, loss or

death to person or property which may be sustained or occur during participating in private sports training through

TotaalVoetbal Concepts, whether or not damages, injury, loss or death is due to negligence.

Parent/Guardian (printed) _______________________________________

Parent/Guardian (signed) ____________________________Date__________

One parent or guardian must attend each session—no drop-offs permitted. Thank you.