WINTER ELITE CAMP APPLICATION 2011

                  January 7-9 th, 2011     @ UAB     $195.00

Name____________________________________________________________

Address__________________________________________________________

City/State/Zip______________________________________________________

Home # (    )____________Daytime # (    )_____________

Parent’s Name_________________________________________

Parent's E-mail Address________________________________________

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

Age at camp _________     Date of Birth______________________

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

Requested training you wish to receive at camp:   ____ Field Player   or   ____Goalkeeper

Grade in School __________   Graduation Year _________

High School Team ___________________________________

High School Coach ________________________    Email ______________________

Club Team  _________________________________________

Club Coach  _____________________________   Email  ______________________

I heard about UAB Soccer Camp thru : 

___ I have been a past camper for_____ years  ___friend 

___brochure mailed ___ my coach  ___ internet search 

___newspaper ad code # ______ 

___ other________________________________

Payment for each camp session must accompany this application. 

Please remember to fill out the medical information.

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 contact:

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.

_______________________________ _________________

Parent or Guardian Signature                      Date

Mail to: Mike Getman Soccer Camp, C/O Mike Getman, 313 Edgewood Blvd., Birmingham, AL 35209