2012REP Team Camp Registration

Play First Name:

Player Last Name:

Address:

City:

State

Zip Code:

Home Phone

E-mail:

Age

Birth Date

MonthDayYear

Grade Fall (2012)

Sex

School Name

Club Team Name

Team Contact/Coach Name:

Position

How did you hear of us?

Comments or Special Requests

This year we will be offering 1 session (6:00pm-8:00pm) during our REP PLAYER/TEAM Camp during the week of July 30 - August 3, 2012. REP/TRAVEL TEAM camp will be for boys and girls from 9-14 years. The location will be at the University of Delaware.

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REP Player/Team Camp August 6 - 9, 2012$125.00

There are NO Discounts Offered for this campFree

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

TEAM CAMPS - Check desired camp

Online registration requires full payment at time of registration. Any cancellations will incur a $75 application fee. If paying by check a $75 non-refundable deposit is due at the time of registration. Full payments are due by July 1, 2012. Registrations after July 1, 2012 will require full payment.

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

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 REP PLAYER/TEAM Camp Registration and Medical Form

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Medical and Contact Information Required