Pro Soccer Kicks - Residential Camp

Male/Female

Residential or Commuter Camp

Entering 5-9th grade girls & boys

(must be entering 6+ for residential)

$495 for residential program

$395 for commuter program

Preferred method of payment: VENMO (free bank/debit transactions. 3% charge for CC) to Carrie-Aristodemo@Aristodemo-PSK

LIKE "ProSoccerKicks" on FaceBook and Instagram for updates and photos during the camp.

Participant Information

First Name *

Last Name *

Grade player is entering; Must be entering 6th for residential *

Year born: *

Position: *

Type of Camper:

If residential, do you have a roommate request?

Adult Primary Contact

Relationship to Participant: *

Mother

Father

Guardian

Other Other

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Cell Phone *

Alternate Phone

Email Address *

Waiver

There are risks connected with my child's participation in this activity including injury and/or exposure to Covid 19. I release, waive, discharge and covenant not to sue Pro Soccer Kicks, event sponsors, Montverde Academy, Minneola Athletic Complex, City of Minneola, Lake County or employees and directors of Pro Soccer Kicks 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

Parent Signature (Acknowledge my typed name will act as my signature): *

Date Signed: *

Insurance Carrier: *

Insurance Card Number: *