Footskills Soccer Camp

Registration

Please fill in the form below to secure a place for your child at Footskills. We will contact you directly to arrange payment. (All fields required. The $75.00 non-refundable deposit must accompany this application by June 30, 2010.)

STUDENT NAME
AGE	MALE FEMALE
WEEKS ENROLLED	1 2 3 4
STREET ADDRESS
TOWN
STATE	ZIP
PARENT/GUARDIAN
EMAIL
HOME PHONE
CELL PHONE
BUSINESS PHONE
EMERGENCY CONTACT
EMERGENCY PHONE
HEALTH & INSURANCE Parents must advise us of any special health conditions or medications taken by the child and submit their insurance carrier’s name and policy # for primary coverage.
INSURANCE CARRIER
POLICY #
I hereby certify that my son/daughter is in good health and able to participate in all camp activities. In case of emergency, I give permission to the trainer or coach of Footskills Soccer Camp to act for me according to his/her best judgement in any emergency requiring medical attention if I cannot be reached. I hereby waive and release trainer or coach of Footskills Soccer Camp from liability for injuries, illness or loss of property incurred while attending camp.
I accept these terms DATE //

(click here to download a print application)