Name: _____________________________________________
Age:_____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:
___ 4 & 5 year olds from 3:15 -
4:15pm, $49*
___
6 - 14 year olds HALF DAY from 9:00am - 12:00pm, $89*
___
6 - 14 year olds FULL DAY from 9:00am - 3:00pm, $170*
___ Session I June 10 - 13
___ Session II June 17 - 20 ___ Session III June 24 - 27
___ Elite Camp participant
*Red Dragon T-Shirt included!
*Cost is per session.
TOTAL Payment
$______
Family
Discount-$10 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
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