DKSC

Direct Kick Soccer Camp REGISTRATION FORM

Fairport High School - Turf, Grass Fields, and Swimming Pool

June 25 - 29, 2018

8:00am - 2:00pm

Kim Kucera, Camp Registrar ... 817-975-7753 ... info@fairportkicks.com

Complete all necessary information below. All fields in Parent/Guardian Section are required.
Complete Camper Section for each individual camper in your family.
Payment options will be on page following submitting the form below.
-------------------------------------------------------------------------------------------------------------------------------------------
PLEASE COMPLETE ALL FIELDS IN THIS SECTION
 

Parent/Guardian Information

Last Name: First Name:        
Street: City: State: Zip:
    Email:
Home Phone: Work Phone: Cell Phone:
Emergency Contact: Emergency Phone:
Insurance: Policy Holder: Policy No:
-------------------------------------------------------------------------------------------------------------------------------------------
 

Camper 1 Information

Last Name: First Name: Age: Gender:
            DOB:
Street: City: State: Zip:
- Mighty Mites: ages 7-10 - June 25 - 29, 2018 - 8AM-2PM    
- Juniors: ages 11-15 - June 25 - 29, 2018 - 8AM-2PM    
- Little Tykes: ages 5-7 - June 25 - 29, 2018 - 9AM-11AM    
Camper 1: T-Shirt Size:    
-------------------------------------------------------------------------------------------------------------------------------------------
 

Camper 2 Information

Last Name: First Name: Age: Gender:
            DOB:
Street: City: State: Zip:
- Mighty Mites: ages 7-10 - June 25 - 29, 2018 - 8AM-2PM    
- Juniors: ages 11-15 - June 25 - 29, 2018 - 8AM-2PM    
- Little Tykes: ages 5-7 - June 25 - 29, 2018 - 9AM-11AM    
Camper 2: T-Shirt Size:    
-------------------------------------------------------------------------------------------------------------------------------------------
 

Camper 3 Information

Last Name: First Name: Age: Gender:
            DOB:
Street: City: State: Zip:
- Mighty Mites: ages 7-10 - June 25 - 29, 2018 - 8AM-2PM    
- Juniors: ages 11-15 - June 25 - 29, 2018 - 8AM-2PM    
- Little Tykes: ages 5-7 - June 25 - 29, 2018 - 9AM-11AM    
Camper 3: T-Shirt Size:    
-------------------------------------------------------------------------------------------------------------------------------------------
 

Camper 4 Information

Last Name: First Name: Age: Gender:
            DOB:
Street: City: State: Zip:
- Mighty Mites: ages 7-10 - June 25 - 29, 2018 - 8AM-2PM    
- Juniors: ages 11-15 - June 25 - 29, 2018 - 8AM-2PM    
- Little Tykes: ages 5-7 - June 25 - 29, 2018 - 9AM-11AM    
Camper 4: T-Shirt Size:    
-------------------------------------------------------------------------------------------------------------------------------------------
It is understood that the Direct Kick Soccer Camp and all its employees are not responsible for accidents resulting in medical, dental and/or other expenses including but not limited to the loss of personal items. It is my intention by my signature that the Direct Kick Soccer Camp and all its   employees be completely released and that I assume all risks to the extent permitted by law. The camper must be in good physical and mental health and be able to participate in the physical activity of a vigorous program. In the event the camper needs to see a physician or requires emergency hospital care, the parent/guardian’s personal medical insurance is responsible for all costs incurred.
By submitting this form and registering my child (children) I give my consent to the Direct Kick Soccer Camp, using their best judgment, to administer First-Aid and/or transport to a facility for medical treatment if I or the emergency contact person cannot be reached.
  Please verify that all information is accurate.
 

Click SUBMIT to take you to Payment Option on next page