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LIGHTHOUSE SOCCER CLUB 2010
CAMP REGISTRATION FORM
MAKE CHECKS PAYABLE TO: Lighthouse Soccer Club MAIL TO: Lighthouse Soccer Club PO Box 11562 Philadelphia, PA 19116
Visit us online at http://www.lighthousesoccer.org/
The 10th annual camp will
be held Camp costs: One Child $65.00, second child from same family $55.00, third, fourth child from same family $45.00. PLEASE Circle One: New Registrant Player Returning
Registrant Last Name: ___________________________ First Name:
_______________________________ Address:
______________________________________________________________________ City: _________________________________ State: _______ Zip:_____________________ Birthdate: _____/_______/_________ Sex: M
F Email:
__________________________ School Child Attends:
___________________________________________________________ Parent/Guardian Name (PRINT):
__________________________________________________ Medical Problems:
______________________________________________________________ Years of Soccer Experience: ___________________ Travel Experience: ___________________ MEDICAL INSURANCE: Lighthouse Soccer Club
requires that you disclose a primary medical insurance carrier. Failure to comply will disqualify applicant
from participating in Lighthouse Soccer Club programs. Carrier
Name: ________________________________________ Policy #:
___________________________________ RELEASE STATEMENTNOTE: The statement should be
signed by a parent/guardian for minor player, an adult player himself; coach
for himself; and administrator for himself.
I, the parent/guardian of the registrant, a minor, or adult registrant
of legal age, agree that I and the registrant will abide by the rules of the
EPYSA, it’s affiliated organizations and sponsors. Recognizing the possibility of the physical
injury associated with soccer and in consideration for the EPYSA accepting
the registrant for its soccer programs and activities (the “Programs”). I herby release, discharge and/or otherwise
indemnify the EPYSA, its affiliated organizations, and sponsors, their
employees and associated personnel, including the owners of the fields and
facilities utilized for the Programs, against any claim by on or behalf of
the registrant as a result of the registrant’s participation in the Programs,
and/or being transported to or from the same, which transportation I herby
authorized. PARENT/GUARDIAN OR ADULT
SIGNATURE: ___________________________________________ |