2016 UMBF Soccer + Health Summer Clinic

Registration Type
Participant Info

Have you played in:

  • A club team
  • A house/recreation league
  • A travel team


Parent/Guardian Info
Emergency Contact Info
Any Additional Information
Clinic Registration - Waiver

I hereby give my consent for:

to participate in The Ucal McKenzie Breakaway Foundation clinics. To be eligible for participation in The Ucal McKenzie Breakaway Foundation, this waiver must be on file with the Community School and this certificate of consent filled out by a parent or guardian.

Parent's or Guardian's Permission And Release

The Ucal McKenzie Breakaway Foundation has no responsibility to provide first aid at any of the community school athletics and the parents or guardian understands that the risk of injury is assumed bythe student and parent when they sign this form. However, in the event physicians, physical therapists, physician’s assistants, nurses, or other persons trained in the rendering of first aid are available, as volunteers or otherwise, and render aid to any student injured during the course of any such activities or travel, the parents do hereby release and forever discharge such persons and The Ucal McKenzie Breakaway Foundation from any liability arising out of any first aid or immediate treatment of injuries.

Statement Regarding Accident Insurance Waiver

We/I the undersigned are completely aware that The Ucal McKenzie Breakaway Foundation DO NOT provide accident insurance for ANY child or adult participating in the aquatics programs offered by The Ucal McKenzie Breakaway Foundation and assumes NO LIABILITY for injuries sustained from participation. We/I, the undersigned, further acknowledge and agree that The Ucal McKenzie Breakaway Foundation will not assume any liability for any injuries sustained by participation in the program. We herein release the The Ucal McKenzie Breakaway Foundation, its agents, representatives, employees and the like from any and all liability related to the participation in the programs offered by The Ucal McKenzie Breakaway Foundation.