Camp # & Location ___________________Dates ______Times_____

Players Name: _________________Age/DOB__________/______M/F__

Address: _____________________________________________

City: __________________________State_____ Zip _________

Home Phone: (____) ____________Emergency: (____) __________

E-mail: __________________@___________________________

Current soccer club: ______________________Rec: ___ Select___

Ball size (add $20 to camp fee) 4 5

Shirt Size (circle) Youth M L

                           Adult S M L

*Bring lunch, snacks, drinks, ball, sunscreen, shin pads, proper attire for outdoor /indoor and bad / cold weather and bring a smile accompanied with a great attitude! Be prepared to work hard and to be challenged!

*I understand that my deposit is non-refundable if my child withdraws within 2 weeks of the start date. Enclosed is my check for $ _______ ($100.00 deposit) made payable to Coerver Coaching (or follow local instructions)

Signed _______________________________Date ____________

RELEASE OF LEGAL GUARDIAN ON BEHALF OF A MINOR

As a parent/guardian of the applicant, I hereby give permission for my child to participate in the Coerver Coaching Southeast USA program, and agree to comply with all program regulations. I hereby remove the campsite, staff, management of local organization and Coerver Coaching from any liability for injuries incurred during my child’s participation in this program.

I, the undersigned parent/guardian, do hereby authorize the athletic trainer or coaches at Coerver Coaching or local organization to secure any and all medical treatment in the event that I cannot be contacted. I further authorize any attending physician to render any and all medical care he may deem necessary.

Signed ___________________________ Date _____________