Soccer Clinic Registration
Participants Details
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Current Age
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home/Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
*
example@example.com
School Year
*
Please Select
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Gender
Male
Female
Shirt Size
*
Please Select
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
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Parent Details for Correspondance
Parent/Guardian Name
First Name
Last Name
Parent Mobile Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent email
example@example.com
Emergency Contact 1
Emergency Contact Name
First Name
Last Name
Home Phone
*
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Relationship to Participant
*
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Medical Details
Health Card Number
*
Expiry Date
-
Month
-
Day
Year
Date
Does the participant have any dietry requirements
Yes
No
Please specify
Is the participant known to have
Diabetes
Fits of any type
Dizzy spells
Blackouts
Travel Sickness
ADHD or similar
Heart Condition
Asthma
Migraines
Epilepsy
Bed Wetting
Sleep Walking
Aspergers Syndrome
Learning Difficulties
Allergies
Other
Please provide details
Will the participant be bringing any medication to the camp?
Yes
No
If Yes, please provide details
Who will administer the medication
Please Select
Participant
Leader
Family Member
Is there any other information about the participant that you should disclose in order to protect their, or others, health, safety, comfort, or wellbeing?
Yes
No
If Yes, please specify
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Registration confirmation
I understand that my camp registration is NOT confirmed until my payment has been received in full by the due date.
*
Yes
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