Pro Soccer Kicks - DeWitt Camp Registration

$100 Per Player ($60 for half week)
Make Checks Payable to:
Pro Soccer Kicks
7421F Kimbark Ct.
Baltimore, MD 21237
http://www.prosoccerkicks.com

Participant Information

* First Name

* Last Name

* Sex

* Birth Date

* T-shirt size:

* Type of player:

* Camp Length:

Full Week Camp (Aug 11-15)

Half Week Camp (Aug 11-13)

Adult Primary Contact

* Relationship to Participant:

Mother

Father

Guardian

Other

* First Name

* Last Name

* Address 1

Address 2

* City

* State

* Zip

* Phone

Alternate Phone

* Email Address

Waiver

*

There are risks connected with my child's participation in this activity. I release, waive, discharge and covenant not to sue Pro Soccer Kicks, event sponsors, employees and directors, from all action, suits and demands whatsoever in law or in equity from demand, losses or damages on account of injury including death caused in whole or in part by the negligence of the releasee or otherwise.

In case of an emergency and if I cannot be reached, I the undersigned parent or guardian of the above named child, do hereby consent to any x-ray, anesthetic, medical, or surgical diagnosis or treatment and hospital care deemed advisable and rendered by any licensed physician or surgeon. This authorization is given in advance of any required care to empower a representative or other official of Pro Soccer Kicks to give consent for such treatment as the physician may deem advisable. The authorization is effective unless revoked in writing. I accept full responsibility for any medical expenses incurred as a result of these actions.

Child may not participate in camp unless parent/guardian agrees to the waiver:

Agree

Disagree

* Indicates Response Required


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