Online Camper Registration Form

 

First Name   Street Address
Last Name   Address (cont.)
Date of Birth   City
Age   State
Sex Male Female   Zip/Postal Code
      Home Phone
         
Please provide the following contact information for Campers' Parents
Mother's First Name   Father's First Name
Mother's Last Name   Father's Last Name
Mother's Work Phone   Father's Work Phone
Mother's Cell Phone   Father's Cell Phone
Mother's E-mail   Father's  E-mail
         
Please Enter a Name and Contact Info for an Emergency Contact person:   Please provide the following Child's Health Information:
First Name   Allergies
Last Name   Regular Medictions
Work Phone   Last Tetanus Immunization
Home Phone   Child's Physician
Cell Phone   Name of Medical Insurance
E-mail   Policy Number
         
Requested T-Shirt Size      
         
Check Here if You are interested in Hosting a coach and we will send you hosting details.
Yes, Please Send Me Details on Hosting a Coach.
         
Medical Care Consent and General Release (Please read and check the box)
  I certify that my child is in good physical health and has my permission to participate in all activities of Goal -Line Soccer Clinics. I authorize all medical, surgical, diagnostic, and hospital procedures as may be performed or prescribed by a treating physician for my child, if I cannot be reached in an emergency. I grant Goal-Line Soccer Clinics permission to use my child’s name, picture or likeness in promotion of the camp in printed media or other forms of advertisement and fully renounce any and all claims upon Goal-Line Soccer Clinics for use of this material.
         
Goal-Line Soccer Clinics.
Copyright © 1999 [Goal-Line Soccer]. All rights reserved.
Revised: March 20, 2010