Online Registration

Step 1 of 3

Player Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Player Email and/or Parent*
Player Cell Phone (ID Camper only)
Alternate Email
Birth Date*
Month
Day
Year
School Name
Grade in spring 2025*
High School Grad. Year (ID Camp only)
Primary Position*
Secondary Position
Notable Awards (ID Camp only)
Club Name
Club Coach Phone (ID Camp only)
Coach Email (ID Campers only)
How did you hear about the camp?*

Parent Contact Information
Parent/Guardian Name*
Parent/Guardian Cell Phone*
Day Time Phone (optional)
Parent/Guardian Email*
Parent/Guardian (2) Name
Parent/Guardian (2) Phone
Parent/Guardian (2) Email
Emergency Contact Information
Please list an emergency contact (not a parent)*
Name Phone Number
Medical Release Form
It is the responsibility of the participant’s parents or legal guardians to ensure that the participant is healthy and has no physical problems which would prevent the participant’s participation in soccer activities. Responsibility for primary medical insurance coverage rests with the participant or their parents or legal guardians.
COVID Medical Liability Waiver
In participating in CISA Club, the undersigned acknowledges, appreciates, and agrees that: 1. The risk of injury and/or illness from the activities involved in the program is unlikely but possible, and while particular practices, rules, equipment, and personal discipline may reduce the risk, the risk of injury or illness does exist; 2. The risk to have contact with individuals, who have been exposed to and/or have been diagnosed with one or more communicable diseases, including but not limited to COVID-19 or other medical conditions, diseases, or maladies does exist, and it is impossible to eliminate the risk that I could be exposed to and/or become infected through contact with or close proximity with an individual with a communicable disease; 3. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of staff associated with CISA, and assume all full responsibility for my child’s participation; 5. On behalf of my child participating in the club, I hereby release and hold harmless CISA and their employees, other participants, and if applicable, owners and lessors of the premises used to conduct the club team, WITH RESPECT TO ANY AND ALL INJURY, ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. 6. 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 AGREEING TO IT ON MY OWN BEHALF OR ON BEHALF OF THE YOUTH PARTICIPANT ASSOCIATED WITH THIS GUARDIAN ACCOUNT, AND I SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. Acknowledgement by Parents and or Legal Guardian of youth participant: By acknowledging and agreeing, I agree to and verify the following: 1) I consent and agree to assume the risks of participation in the club team programing; and 2) that I specifically agree to the release as provided herein of CISA and Staff, and, for my child, I release and agree to indemnify CISA and Staff from any and all liabilities incident to my child’s involvement or participation in the club team even if arising from the negligence of the CISA and Staff.
Refund Policy
Refunds will not be offered for the Women’s Soccer Elite ID Clinic at Illinois State University, however, your clinic credit can be applied to a future clinic. For CISA camps in Peoria, a refund may be given when we receive written notice from a physician stating that the athlete is physically unable to participate in the team. Refund requests will be reviewed by the club administrator for validity. All approved refunds for the Peoria-based camps will incur a 5% administration fee which will be deducted from your refund amount.
Medical Insurance Company*
Policy Holder*
Policy Number*
Special Medical Needs
Do you certify that this player has had a physical examination by a licensed physician in the past year and is free from any illnesses or injuries that would prevent the participant from participating in any activities at the Central Illinois Soccer Academy.*
- Yes
Do you agree/confirm the terms of the medical release waiver, COVID-19 medical waiver, and refund policy?*
- Yes

Online Registration

Step 1 of 3

Parent Contact Information

Emergency Contact Information

Medical Release Form

Registration Options

Billing Information

Name	Phone Number