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 July 26-30, 2009
Lighthouse Soccer Camp is a great opportunity for both beginner and advanced players
to train with some of the areas most qualified soccer coaches. We have a great staff!

Everyone receives a ball, shirt, and we provide water ice and pretzels every night. It’s a fun week, so come out and enjoy new friends and playing good soccer.

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: ______________________________________________________________________

Home Phone #: (_____) _______-__________ Cell Phone #: (_____) _______-__________

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 STATEMENT

NOTE: 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: ___________________________________________

DATE: ___________________