Potsdam, Massena post wins

Soccer

CAMP REGISTRATION FORM

CAMPER(S) NAME: ________________________________

PARENT NAME(s): _________________________________

ADDRESS: ____________________________________________________________________________________________________

CITY: ________________________STATE_______ZIP________

SCHOOL__________GRADE as of 9/2019: ____

GOALIES ONLY CAMP (Check Here) _________

PARENT/GUARDIAN PHONE -: _____________________ WORK PHONE: _______________

BACK-UP EMERGENCY CONTACT NAME/PHONE -: _________________________________

T-SHIRT SIZE: ADULT ONLY_____

EMAIL ADRESS____________________________

Parental release: This is to certify that my student athlete has permission to participate in all camp activities. I assume all risks and hazards incidental to such participation and I do hereby agree to hold harmless the staff of the Lisbon Soccer Camp from all claims arising out of any injury to my child. Furthermore, this verifies that the camper is up to date with his/her immunizations and can participate in all camp activities. In the event of injury my permission is granted for treatment as required at the nearest medical treatment facility.

ASTHMA___________ BEE STING ALLERGY___________ (Athlete MUST have Bee Sting Kit and/or Asthma Inhaler)

ALLERGIES: __________________________________________________________

ANY/ALL OTHER MEDICAL CONDITIONS: ______________________________________________

CURRENT MEDICATIONS TAKEN: ____________________________________________________

Parent/Guardian Signature: ____________________________________ Date: _____________________

Johnson Newspapers 7.1

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