WA SUMMER SOCCER CAMP

PO Box 540, Imperial, PA 15126
 
Name:
 _____________________________________________________________
 
Address:
 _____________________________________________________________
   
City/ST/Zip:
 ____________________________ ST ____ Zip __________________
   
Parent/Guardian:
 _____________________________________________________________
 
Contact Info:
 H phone ______________ Other phone ______________
 
  Male___ Female ____Age ____ Grade ____
   
Camp:
 Future Stars($40.00)_____ Jr. Pros($65.00)_____
   
Ins. Company:
 _________________________________________________
   
Policy/Group #:
 _________________________________________________
   
T-Shirt Size:
 (please circle one): YS - YL - S -M -L - XL
   
  List any relevant medical conditions/medications taken/injuries/allergies
   
  __________________________________________________________
 
Parental Consent and Liability Waiver

I, the above named parent/guardian, give permission for my child to participate in the WA soccer camp. I understand the camp program involves physical activity and accept the risks and hazards incidental to such participation. I agree to hold harmless the camp director, staff, agents and/or sponsors from liability for injuries to my child which may be sustained while participating in this program. I certify my child has been examined by a physician in the past year and is in satisfactory health to participate in these activities. I understand camp staff cannot be responsible for loss or damage to my child’s personal possessions.

   
  Guardian Signature ________________________________________
   
   
Refund Policy:
 100% reimbursement, if camper withdraws prior to the start of camp
   
   
  Please make your check payable to: WA Soccer Camp