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LIGHTHOUSE SOCCER
CLUB
2008 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 8th annual camp will be
held July 7 -11 2008.
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. At the end of the week, there are contests and prizes for
our players for displaying the skills they learned! 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:
___________________
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