ACYSO 2012 SUMMER CAMP

ACYSO 2012 SUMMER CAMP
Player Information
Full Name

First NameLast Name
Gender
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Shirt Size
E-mail Address
Camp(s) Attending
My Products
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July 16-18 M-W Full Day$150.00

July 16-18 M-W Half Day$100.00

July 19-20 Th-F Full Day$100.00

July 19-20 Th-F Half Day$65.00

July 16-20 Extra Care Morning$25.00

July 16-20 Extra Care Afternoon$25.00

July 23-25 M-W Full Day$150.00

July 23-25 M-W Half Day$100.00

July 26-27 Th-F Full Day$100.00

July 26-27 Th-F Half Day$65.00

July 23-27 Extra Care Morning$25.00

July 23-27 Extra Care Afternoon$25.00

Total $0.00
Medical Information
As the parent/guardian of the above named player, I request that in my absence the above player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named player.
Medical Authorization
Date of Last Tetnus Booster

MonthDayYear
Known allergies of this player, including any allergies to medicine
Any other medical problems which should be noted
Family Physician
Insurance Carrier
Policy #
Name of Parent/Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Person responsible for charges (if different from above)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Person to notify if parent/guardian is unavailable

First NameLast Name
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Legal Stuff
I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of STYSA, it's affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration by the USYSA, accepting the registrant for its soccer programs and activites (the "Programs"). I hereby release, discharge and/or otherwise indemnify the USYSA, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant's participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize.
Authorization
Authorizing Parent/Guardian
Should be Empty:

ACYSO 2012 SUMMER CAMP

Player Information

Camp(s) Attending

My Products

Medical Information

Legal Stuff