DKSC

Pre Varsity Soccer Camp: REGISTRATION FORM

Fairport High School Turf & Grass Fields

July 9 - 12, 2018

8:00am - 12:00pm

Camp Cost: $120 per Camper | Family Discount: $80 each additional camper per family

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

Complete all necessary information below. All fields in Parent/Guardian Section are required.
Payment options will be on page following submitting the form below.
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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:
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Camper 1 Information

Last Name: First Name: Age: DOB:
Street: City: State: Zip:
Camper 1: T-Shirt Size:    
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Camper 2 Information

Last Name: First Name: Age: DOB:
Street: City: State: Zip:
Camper 2: T-Shirt Size:    
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Camper 3 Information

Last Name: First Name: Age: DOB:
Street: City: State: Zip:
Camper 3: T-Shirt Size:    
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Camper 4 Information

Last Name: First Name: Age: DOB:
Street: City: State: Zip:
Camper 4: T-Shirt Size:    
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It is understood that the Pre-Varsity 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 Pre-Varsity 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