Print this form and mail with payment to:
Red Dragon Soccer Academy
PO Box 2517, Vero Beach 32961

Name:   _____________________________________________ Age:_____

Home Phone: ________________  Emergency Phone/s:_________________, _________________

Parents/Guardians Name(s) _________________________________________________

Address ______________________________City_____________________Zip_____________

E-Mail: _________________________________________________________
           We must have an email address for confirmation and updates - please print clearly

Please check the appropriate information:

___ Session I, June 8 - 12        ___ Session II: June 15 - 19        ___ Session III: June 22 - 26

___ Half-Day, $95*    ___ Full-Day, $175*

*Red Dragon T-Shirt and ball included!      

TOTAL Payment         $______
Family Discount-$15 off after 1st child

As a parent/guardian of the applicant, I hereby give permission for my child to participate in the Red Dragon Soccer Academy camp and/or program, and agree to comply with all the program regulations. 
I hereby remove the camp, staff, management and Red Dragon Soccer Academy from any and all liability for injuries incurred during my child's participation in this program.
I, the undersigned parent/guardian, do hereby state that my child is medically qualified to attend the Red Dragon Soccer Academy Camp.
I hereby authorize Red Dragon Soccer Academy to act for me according to their best judgment in any emergency requiring medical attention. 
I hereby give permission for a physician and/or hospital emergency room to provide necessary care.
I authorize use of any photo/video taken of my child during the camp for Red Dragon Soccer Academy materials.

Parent/Guardian Signature _______________________________Date: ____________

Health Insurance Provider________________________________

Policy # ___________________________________________

For Office Use Only       Check #                    Date