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“Soccer Made Simple” Instructional Camp by Dave Fernandez (Day camp)

Child First Name

Child Last Name

Grade Entering

Grade Entering Fall 2016

Email Address

Confirm Email Address

Parent Name

Primary Phone Number

6185551212 (or) 618-555-1212

Street Address

City

State

Zip Code

Payment

Pay By Check

Please send check payable to:
Glen-Ed Soccer
℅ Chuck Hentz
7024 Stallion Dr.
Edwardsville IL 62025

Disclaimer

- I certify that my child is in normal health and capable of participation in this soccer program. I further understand that participation in this soccer program involves risk and possible injury and represent to the soccer camp director, coaching staff, Glen-Ed Sports Association, that my child has medical health insurance to cover any injuries sustained as a result of participation in this soccer program. It is agreed that the soccer camp director and/or staff assume no liability for injuries sustained as a result of participation in this program. I authorize the camp director and/or soccer camp staff to secure emergency medical treatment should my child require it.