Registration

Choose Camp
  ------------------------ June 18-22 July 20-24
Camper's Name

Birthdate

Parent/Guardian Name

Relationship

Allergic
NoYes
If yes, please explain.
Reactions to drugs, food, asthma?

Emergency Contact Information

Name of parent or guardian to contact

Home Phone

Work Phone

Cell Phone

Medical Insurance Information

Name of insurance company

Name of policy holder

Policy Number

Additional Instructions Regarding Insurance

Camp Application

Camper's Address

City

State

Zip

Email Address

Age

Birthdate

Grade (as of 9/1)

If you are attending camp as a team, team name

Roommate Request

Sex
MaleFemale

Method of Payment
Online PaymentMailing a Check

Ben Freakley School of Soccer Release Statement

By submitting this form, I / We, the undersigned hereby certify that I (We) am (are) the parent or legal guardian of the camper. I hereby give my permission for the staff of the camp,during the period of the camp, to seek appropriate medical attention for the camper, and for medical attention to be given, and for the camper to receive medical attention in the event of an accident, injury or illness. I / We will be responsible for any and all costs of medical attention and treatment, and have medical insurance to cover these costs. I / We understand, as with any sport, injuries can occur, and we hereby acknowledge that our child is physically fit and mentally capable of participating in soccer and camp activities.

Signature (Full Name of Form Submitter)