2012 Day Camp Registration

Camper First Name:

Camper Last Name:

Address:

City:

State

Zip Code:

Age

Birth Date

MonthDayYear

Grade Fall (2012)

Sex

Club Team Name

Home Phone

E-mail:

How did you hear of us?

T-Shirt Sizes (Youth)

We will be offering 2 weeks of Day Camps at the University of Delaware this summer! Weeks One & Two of DSC Day Camps at University of Delaware from 9am - 3pm for boys and girls 7-12 years of age. These camps include 1 hour of time in the UDEL outdoor pool. The CAA Soccer Day camps have been CANCELED

To Pay with Credit Card

DSC Wk 1 - June 18-22, 2012$225.00

DSC Wk 2 - June 25-29, 2012$225.00

After Hours (DSC Wk1 & Wk2$75.00

WK 1 w/ Multi/Sibling Discount$215.00

WK 2 w/ Multi/Sibling Discount$215.00

WK 1 w/ Team Discount$210.00

WK 2 w/ Team Discount$210.00

Total $0.00

Online registration requires full payment at time of registration. Any cancellations will incur a $75 application fee. If paying by check at $75 non-refundable deposit is due at the time of registration. Full payments are due by May 31, 2010. Registrations after May 31, 2011 will require full payment.

** Discounts cannot be combined

***CHECK BELOW IF SUBMITTING A CHECK BY MAIL ONLY!***

Please choose week(s) desired:

Discounts/Additional Services Offered: Choose if applicable

** Discounts cannot be combined

COMMENTS or Special Requests:

Mother's First Name

Mother's Last Name

Mother's Day Phone

Mother's Cell Phone

Father's First Name

Father's Last Name

Father's Day Phone

Father's Cell Phone

IF PARENTS/GUARDIANS CANNOT BE REACHED, PLEASE CALL THE FOLLOWING:

Emergency Contact #1 Name/Phone Number

Emergency Contact #2 Name/Phone Number

Family Physician Name

Family Physician Number

IN THE BOX BELOW, PLEASE EXPLAIN ANDY SERIOUS MEDICAL CONDITIONS AND LIST THE NAMES OF ANY MEDICATIONS THE CAMPER IS PRESENTLY TAKING AND FOR WHAT MEDICAL CONDITIONS

Medical Conditions

Allergic to

Other Allergy

Medical Insurance Company

Policy Number

Are you insured by any other health benefit plan such as an HMO. Please specify

The above Camper has been examined within the last 12 months and no medical reason has been found that he/she can not participate in this camp. Records show that all immunizations are up to date.n
I agree that In case of an accident involving my child while attending camp and with full awareness that soccer is an activity that may involve risk or injury, I release Delaware Soccer Camps and the University of Delaware from any and all liability. In case of an emergency, I give permission to have my child properly transported to a medical facility for care. I understand that Delaware Soccer Camps and the University of Delaware do not provide medical insurance and that I will be responsible for all medical expenses incurred. Delaware Soccer Camps has established the following procedure for injury or sickness: (1) the camp will call home. (2) call the father’s, mother’s or guardian’s place of employment, (3) call the emergency numbers and physician, (4) call an ambulance if necessary for transportation to medical facility, (5) attending physician will make judgment of admittance, (6) Delaware Soccer Camps will continue to call parents , guardian or physician until one is reached. If I cannot be reached and the camp has followed the above procedures, I assume all expense for the transportation and medical treatment. I also hereby consent to any treatment, surgery, diagnostic procedure, or the administration of anesthesia which may be carried out based on the medical judgment of an attending physician.

Medical Waiver

DELAWARE SOCCER CAMPS 2012 Day Camp Registration and Medical Form

To Pay with Credit Card

Medical and Contact Information Required