Team Camp APPLICATION 2010

Camper's Name____________________________________________________________

Address__________________________________________________________

City/State/Zip______________________________________________________

Home # (    )____________   Daytime # (    )_____________

Parent’s Name_________________________________________

Parent's E-mail Address________________________________________

(we send your registration confirmation & camp infomation by email, so please print neatly.)

Age at camp _____   Date of Birth__________   Grade Next Yr_______  Graduation Year ______

Circle T-shirt size, Adult: S   M   L   XL

Indicate training you wish to receive at camp:   ____Field Player  or   ____Goalkeeper

I am signing up for:

    June 13 - 17

Team Camp         ____Overnight ($500)  ____Commuter ($425)

(must be registering as part of a team)

Team Name ________________________________________

____ I have enclosed $25 to purchase a Nike soccer ball.

A $100 deposit for each session of camp must accompany this application.

After April 1st, send full payment.

Application - Medical Information

Camper's Name___________________________    Date of Birth _______________

Medical Insurance Company Name & Policy Number ___________________________

__________________________________________________________________

Emergency Phone #s

Father  (home)__________________(work)________________(cell)_____________

Mother (home)__________________(work)________________(cell)_____________

In an emergency, if parents cannot be reached notify:

Name____________________________ Relationship________________________

Phone#____________________________________________________________

Family Doctor _________________________ Phone # _______________________

Known Allergies______________________________________________________

Asthma _____________________________

Diabetes _____________________________

Last Tetanus Shot or Booster __________________

List of Medications Currently Taking ______________________________________

___________________________________________________________________

I, the undersigned Parent/Guardian of the above named participant acknowledge that I understand and hereby consent as follows: 

I understand and acknowledge that there are some risks involved in participation, including but not limited to risk of physical injury, and that I agree to release and discharge the Mike Getman Soccer Camp, LLC. (Camp), its employees and agents and The Board of Trustees of the University of Alabama ("the Board"), The University of Alabama at Birmingham ("UAB"), their officers, directors, employees and agents from any and all liability, claims, demands and causes of action or other loss suffered by the participant in connection with participation in the camp excepting only liability, claims and expenses arising out of the sole negligence of the Mike Getman Soccer Camp, LLC., the Board, UAB or the officers, directors, employees and agents thereof.

I warrant and represent, to the best of my knowledge and belief, that the participant is healthy and able to participate in the Camp, and I agree to notify Camp administrators of any allergies or other physical, mental or emotional condition that might limit the participant's ability to safely participate  in the Camp activities.

I give permission to the Mike Getman Soccer Camp, LLC., its trainers or other staff members, agents and any attending physician to provide such emergency care and treatment to the participant as in their judgment may be deemed necessary or advisable in the event that the participant should require emergency care while participating in the Camp.  I agree to assume the costs of such emergency care and treatment, if any such costs are incurred.

I give the Mike Getman Soccer Camp, LLC permission to transport my child by a licensed amd insured bus company during the course of camp activities.

_______________________________ _________________

Parent or Guardian Signature                    Date

Make Check Payable to: Mike Getman Soccer Camp, 313 Edgewood Blvd., Birmingham, AL 35209

Fax # 205 877-8473