CAMP APPLICATION FORM
Camper Name ............................................................................................................ Age................M............F............
School ......................................................................................................Position .......................................................
Camp date .................................................. Camp Description: Team Camp / Evening Camp (circle one)
T Shirt YS.......YM.........YL............AS..........AM..........AL.......... AXL...........
Parent/Guardian.............................................................................................................................................................
Address.........................................................................................................................................................................
City ............................................................................St.................................................Zip ........................................
Phone.......................................................................... E mail.......................................................................................
Emergency contact name..............................................Work.............................................Cell ......................................
RELEASE OF LIABILITY AND AUTHORIZATION FOR MEDICAL TREATMENT
In consideration of my child being permitted to participate in the Soccer Etc LLC Soccer Camp, I, the undersigned parent/guardian, in full recognition and appreciation of the dangers and hazards inherent in participating in the Camp and in the circumstances to which my child may be exposed during participation in the Camp, do hereby agree to assume all the risks and responsibilities surrounding and pertaining to my child's participation in the Camp, and Further I do for myself and my child's personal representative(s), heirs and assigns, hereby agree to defend, hold harmless, indemnify, release and forever discharge Soccer Etc LLC and North Rutherford Soccer, and all its officers, agents and employees from and against any and all claims, demands and actions, or causes of action, on account of damage to personal property, personal injury, or death which may result from my child's participation in said Camp which results from causes beyond the control of a, and without the fault or negligence of, Soccer Etc LLC and North Rutherford Soccer, its officers, agents or employees, during the period of m child's participation in the Camp. Further, I hereby grant permission to the camp director and/or other Soccer Etc officials the right to seek and/or administer appropriate medical aid to my child in the event of an emergency. In witness whereof, I have caused this Assumption of Risk, Release and Medical Authorization to be executed this ............day of ................2011
Insurance Company:.....................................................Family Doctor .......................................Phone: ..........................
Parent/Guardian Signaturre: .......................................................................................Date: ...........................................
(Please enclose a photocopy of your insurance card front and back)
Payment: Return completed application form and payment to:-
Soccer Etc LLC, c/o 1299 Bridgestone Parkway, Lavergne, Tennessee, 37086
Call or email with any questions: (615) 456 2567
clementsnj@aol.com
