PATRIOT SOCCER CAMP

Sponsored by Seminole Youth Soccer

Registration Form - Summer 2011

                                  

Name 1 _____________________   Age _____     Name 2 _____________________   Age _____



Name 3 _____________________   Age _____     Name 4 _____________________   Age _____



Parent/Guardian:   ___________________________________________________



Address: _____________________________________  City:  _________________  Zip ________



Home Phone: ________________  Work Phone: _________________  Cell Phone: ______________



Email address: _________________________________________________________



Session(s) your child(ren) will be attending:



_____  Session #1       June 20-24          Full-Day $175



_____  Session #1	June 20-24 	    Half-Day $110



_____  Session #2       July 11-15          Full-Day $175



_____  Session #2  	July 11-15          Half-Day $110



_____  Session #3       August 1-5          Full-Day $175



_____  Session #3	August 1-5          Half-Day $110



_____  All Three Sessions                   Full-Day $500



_____  All Three Sessions                   Half-Day $300

Parent or Guardian Consent Form

In case of injury to my child, I/We likewise waive the right to the extent not covered by liability insurance, and claim against persons working in this camp. I/We likewise hereby authorize any medical treatment which the directors of the camp deem necessary in any emergency situation. The camper is covered by insurance. I/We believe our child is physically fit to participate in this camp. Please list below any medical conditions or medications the camper may have or need. ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 

Insurance Company: ________________________________  Policy Number: ____________________________



Parent/Guardian Signatures _________________________________________



                           _________________________________________

Confirmation Notice

When we receive your registration and payment, we will send you a confirmation letter, which will include more information. This letter will serve as your receipt. 

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