Tulsa Roughnecks & Fortuna Tulsa 2019 - Tedford Insurance Clinic

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Players Name* This field is required.
First Name
Last Name
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Players D.O.B* This field is required.
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Players Gender* This field is required.
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Players Current Team(If any, answer 'none' if not on a team)
5
Players Soccer Background(e.g. Played recreational soccer for 4 years)
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6
Players Medical Conditions
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Parent/Guardian Name * This field is required.
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Parent/Guardian Contact Number* This field is required.
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Phone Number
9
Parent/Guardian Email* This field is required.
example@example.com
10
Camper Liability and Health Information. I the undersigned, hereby certify that I am the parent or legal guardian of the camper. I hereby give permission for the staff of the camp to seek appropriate medical attention and for medical attention to be given in case of accident, injury or illness. In addition, I will be responsible for any and all costs of medical attention and treatment. I the undersigned, for myself, my family and heirs, waive, release and forever discharge the Camp staff, officers and representatives, from any and all liability, claims, demands or actions whatsoever arising out of or related to any loss, personal injury or property damage that may be sustained or occur during participation in camp activities or while at camp. I also understand that the Camp retains the right to use photographs of campers taken at the Camps for publicity and advertising purposes. I sign below to show my acknowledgement. * This field is required.
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Date of Signature* This field is required.
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12
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ORDER SUMMARY
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Roughnecks & Fortuna Camp Fee
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