Premier Youth Soccer Academy - Contact & Registration

	("*" indicates required field)

Camp Dates:	November 21 - 23 (3 Day Fall clinic) December 26 – 28 (3 Day Winter Camp)

	Parent / Guardian Information
*Email:
*Re-Type Email:
*First Name:
*Last Name:
Address:
City:
State:	Zip Code:
Home Phone:
Cell Phone:

	Camper Information
1st Child:	Age : Sex : Position:
2nd Child:	Age : Sex : Position:
3rd Child:	Age : Sex : Position:

	Medical Information All campers must have their own medical coverage. Campers will not be allowed to participate unless the medical information is submitted and the waiver below is signed.
Health Insurance Carrier:
Policy Number:
Doctors Name:
Doctors Phone:
	Medical problems we should be aware of:
	Payment $85 Fall clinic; $95 Winter camp (Cash or checks please - made out to Burgi Hoffman)
	Agreement and Release from Liability
	Please read the waiver carefully By checking the box below, you agree, warrant and covenant as follows: 1) I am aware that soccer is a contact sport and is a hazardous activity which presents special risks to players resulting from falls and collisions and may result in bone fractures, head injuries, sprains, strains, and other injuries. I am allowing my child to voluntarily participate in these activities with knowledge of the danger involved. 2) I, the undersigned, hereby certify that I am the parent or legal guardian of the camper or campers. I state that the camper (campers) is (are) in good health and has permission to participate in camp activities. I hereby give permission to the staff of the Soccer Skills Camps, Premier Youth Soccer Academy and Premier Youth Soccer Academy Camps “hereafter PYSA”, to seek during the period of the Camp, appropriate medical attention for the camper (campers) and for the medical attention to be given and for the camper (campers) to receive medical attention in the event of accident, injury, or illness. I will be responsible for any and all costs of medical attention and treatment. I, the undersigned, for ourselves, our heirs, executors and administrators, waive, release, and forever discharge PYSA and its staff, officers, agents, employees, representatives, successors and assigns from any and all liability, claims, demands, actions, and causes of actions whatsoever arising out of or related to any loss, personal injury, or property damage that may be sustained or occur during participation in PYSA Camp activities or while at the PYSA Camps. I, the undersigned, give permission for all pictures and videos taken at the PYSA Camps to be used at the sole discretion of PYSA. 3) I acknowledge that my child (children) has (have) voluntarily applied to participate in PYSA Camps. 4) I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and a contract between myself and PYSA and its affiliated organizations and sign it of my own free will.
	I agree to the above waiver.