| REGISTRATION:
CHILD'S NAME: _________________________________________
SEX: __________ AGE: __________
ADDRESS: ______________________________________________
______________________________________________
PARENTS: _______________________________________________
PHONE:
HOME: ______________________ (M) ____________________ (D)
WORK: ______________________ (M) ____________________ (D)
CELL: _______________________ (M) ____________________ (D)
EMAIL: _________________________________________________
REGULAR CAMP
________ JUNE 1 - 5 ________ JUNE 22 - 26
________ JUNE 8 - 12 ________ JUNE 29 - JULY 3
GOALKEEPER CAMP *
________ JUNE 8 - 12 ________ JUNE 22 - 26
* One full week of goalkeeper training. Goalkeepers will be in
their own group, working on goalkeeper specific skills.
COST OF CAMP: $100
Group discount: 3-6/$5 off; 7 or more/$10 off **
** Forms must be received together for discount to apply. Sorry, no
exceptions.
T-SHIRT SIZE: YM YL AS AM AL AXL
TRANSPORTATION:
_____ HAS OWN _____ TARGET ON AMBASSADOR
_____ ALBERTSON'S ON JOHNSTON ST.
_____ ALBERTSON'S IN BROUSSARD ***
*** WEEKS OF JUNE 1, JUNE 8 AND JUNE 29 ONLY!
_____ LOWE'S IN CARENCRO +
+ WEEKS OF JUNE 8, JUNE 22 AND JUNE 29 ONLY!
_____ ST. ALPHONSUS CHURCH IN MAURICE ++
++ WEEK OF JUNE 22 ONLY!
AGE GROUP: U-__ TEAM: ____________ COACH: _____________
PLEASE GROUP MY CHILD WITH: ___________________________
___________________________________________________________
___________________________________________________________
EXCLUDING THIS YEAR, MY CHILD HAS ATTENDED
THE JUST 4 KICKS SOCCER CAMP ______ YEARS. |
MEDICAL INFORMATION:
DATE OF CHILD'S BIRTH: ____________________________
DATE OF LAST TETANUS: ____________________________
KNOWN ALLERGIES: ________________________________
_____________________________________________________
_____________________________________________________
KNOWN MEDICAL CONDITIONS: ______________________
_____________________________________________________
_____________________________________________________
FAMILY PHYSICIAN: _________________________________
PRIMARY INSURANCE CARRIER: ______________________
_____________________________________________________
POLICY NUMBER: ___________________________________
I CERTIFY THAT MY CHILD _______________________________
IS IN EXCELLENT HEALTH AND MAY PARTICIPATE IN STRENUOUS PHYSICAL
ACTIVITIES INCLUDING SOCCER AS THE PARENT OR LEGAL GUARDIAN OF THE
ABOVE CAMPER, I REQUEST THAT IN MY ABSENCE, THE ABOVE NAMED CAMPER
BE ADMITTED TO ANY HOSPITAL OR MEDICAL FACILITY FOR DIAGNOSIS AND
TREATMENT. I REQUEST AND AUTHORIZE PHYSICIANS, DENTISTS AND STAFF,
DULY LICENSED AS DOCTORS OR MEDICINE OR DOCTORS OF DENTISTRY OR
OTHER SUCH LICENSED TECHS OR NURSES TO PERFORM DIAGNOSTIC PROCEDURES
AND X-RAY TREATMENT TO THE ABOVE MENTIONED MINOR. FINALLY, I WILL IN
NO WAY HOLD THE LAFAYETTE PARISH SCHOOL BOARD, CHARLES M. BURKE
ELEMENTARY, ITS FACULTY OR ANY INDIVIDUAL ASSOCIATED WITH THE CAMP
RESPONSIBLE FOR INJURIES RECEIVED BY THE PERSON STATED ABOVE.
___________________________________ _______________
Parent or Legal Guardian's Signature Date
___________________________________ _______________
BEFORE YOU SEND YOUR FORM IN, PLEASE MAKE SURE YOU:
* Selected the appropriate week and bus.
* Selected t-shirt size
* Completed team information, if applies
* Completed medical information
* Included check with registration form
* One full week of goalkeeper training. Goalkeepers will be
in their own group, working on goalkeeper specific skills.
Mail completed form and payment to:
JUST 4 KICKS SOCCER CAMP
219 BELLE MAISON DR.
LAFAYETTE, LA 70506 |
|
