| Camper Name: | Circle: Male or Female |
| Street Address: | |
| City, St, Zip: | |
| Home Phone: | |
| School next year (‘08-’09): | Grade next year (‘08-’09): |
| Birth Date: | Current Team: |
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Emergency Information:
| Emergency Contact & Day Phone: | |
| Medical Insurance Co: | Policy #: |
| Family Physician: | Physician Phone: |
| Recognizing the possibility of physical injury associated with the sport of soccer, I hereby release, discharge, and/or otherwise indemnify FSU, the FSU Foundation, its ownership, staff, affiliates and associated personnel, including the owners of facilities utilized by the camp against any claim made by or on behalf of the camper listed above as a result of the camper’s participation in camp activities. I certify that the player above is in sound physical condition and capable of participating in soccer activities and that there are no medical conditions that would prevent his/her participation or be affected or influenced by the above named player’s participation in soccer activities conducted by the Frostburg State University Day Camps. In case of emergency, I authorize treatment to be given by my family physician or the nearest Hospital’s emergency department. I permit the FSU Camp staff to act on my behalf in accordance with their best judgement in any emergency requiring medical attention. | |
Parents Signature: ________________________________________________________
Payment:
(Please make checks payable to:
"Friends of FSU Soccer")
| Check One: Day-Camp Session (8:30-Noon): ________ Extended-Day Session (8:30-3:30):________ |
| _________ $120.00 mail-in registration fee for Day-Camp (prior to June 15) __________ OR $170.00 for Extended Day Session (players will be served a catered lunch) [Pay only $70 (day session) or $120 (extended-day session) if this is an additional child from the same household] |