Summer Camp Registration FormSUMMER CAMP REGISTRATION 2019 2019 Summer Camp Registration Medical and General Information Form Pay By Credit Card Form – Please complete 1 (one) registration form per camper. Please Complete Form Below – Summer Camp New or Returning Camper*Have you been to Panther Soccer Camp before?Choose OneNewReturning Camper Name* First Last Camper Age:*Choose Age5678910111213 Camper Date of Birth* Camper Gender* Female Male Camper Soccer Experience*Please select the soccer skill level that applies to CamperChoose Soccer ExperienceBeginner (0-2 years Played)Intermediate (3-4 years Played)Advanced (5+ years Played) Camper Current Player Level:*Choose Player LevelNoneRecreationSignatureClub Camp T-shirt Size*Please Choose Camp T-shirt Size. Shirts are a 50/50 Hanes.Choose T-shirt SizeYouth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult XLarge Parent / Guardian #1 Please enter contact information for Parent / Guardian #1 Parent / Guardian Name #1 First Last Parent / Guardian #1 Email Address Parent/Guardian #1 Cell Phone: Primary Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Daytime Phone:*Please provide a daytime number where you can be reached during camp. Name of Emergency Contact*Provide Name of Emergency Contact, incase you cannot be reached. First Last Emergency Contact Phone:*Please provide a daytime number where you can be reached during camp. Medical Insurance Provider*Please list the Name of your Medical Purchase Provider. Medical Conditions*Please note any medical conditions that we should be aware of. If none, please state none. Note/CommentsIf you would like a camper grouped with a friend in his/her age group, please state here. How did you hear about Panther Soccer Camp?* Internet Search Friend Email/Flyer Returning Camper Cancellation Acknowledgement*I agree and understand that there is no refund after the first day of camp. I understand there is a cancellation fee of $50 if for any reason I need to cancel my son/daughters registration. I acknowledge and accept the conditions above with my signature below. Waiver & Release of Liability*I understand that there are risks involved with my child’s participation in the Panther Soccer Camp. I hereby authorize the directors of Panther Soccer Camp to act for me according to their reasonable judgment in any emergency requiring medical attention. I hereby waive and release the directors of Panther Soccer Camp from all liability and agree to accept all medical expenses incurred. I know of no physical or mental problem that will affect my child’s ability to safely participate in these camp sessions. I certify that my child is in good health, and may participate in strenuous physical activities at soccer camp. I certify that there are no physical limitations to my child’s participation in the camp. Permission is granted for my child to receive emergency medical treatment if needed. I hereby release and forever discharge Panther Soccer Camp and all their agents, employees and affiliated entities from any and all liability, claims, demands, and cause of action for personal injury or death, property damage, and/or other loss suffered by my child in connection with his/her participation in the tryouts. I acknowledge and accept that this Release and Waiver is intended to be binding on the family, estate, heirs, executors, administrators and assigns of the minor named above. I further acknowledge and accept that this Release and Waiver is intended to be as broad and inclusive as permitted by the laws of California and agree that if any portion of this release and Waiver is invalid, the remainder will continue to be in full force and effect. I agree that this Release and Waiver binds the minor and me to all of its terms. I hereby grant permission to Panther Soccer Camp and its legal representatives, assigns, and those acting on its behalf, to use any picture, video or audio recording of my child taken in connection with the soccer camp for all manner of advertising, trade, promotion, exhibition, or any other lawful purpose related to youth soccer whatsoever and in any form or medium. I hereby release the Panther Soccer Camp and its member leagues, teams, agents, officers, coaches and players from all liability or responsibility for any claim, damage or legal action on behalf of the player or the player’s parents, heirs, or personal representatives, arising from any injury the player may sustain while participating in soccer or related activities. I acknowledge and accept the conditions above with my signature below. Camp Sessions*PLEASE CHOOSE THE FOLLOWING SESSION(S) ATTENDING: S1 June 17-21, 2019 S2 July 22-26, 2019 S1 June 17th – 21st*Half Day (9am-12pm): $120 (after 5/29th $140, if space is available-Walk up $160) Price: $120.00 Quantity: S2 July 22 – 26th*Half Day (9am-12pm): $120 (after 5/29th $140, if space is available-Walk up $160) Price: $120.00 Quantity: Do you have a Coupon Code?If you have a coupon code, please enter that code here. Total $0.00
