Registration

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Player Name

Parent/Guardian Name

Home Phone Number

Cell Phone Number

Address

City, State, Zip

Camper's Age

Camper T-Shirt Size

Medical Information which should include allergies, medications, injuries, etc. If none, list none.

Insurance Carrier

Subscriber Name

Policy Number

Group Number

In the case of any emergency, every attempt will be made to contact the above names parent/guardian from any and all numbers provided. The above named parent guardian by agreeing, authorizes the camp staff to provide or arrange for emergency or medical care if necessary. Any expense arising from injury or illness is solely the responsibility of the camper and the above named parent/guardian.

Waiver Electronic Signature

Nashua Location

$213.32 + $6.68 Processing fee = $220 If you don’t want to pay the processing fee, please email me and we can sort out payment via check. Additionally, if you have siblings attending camp, please email me for sibling discount. (lauraraysoccercamp@gmail.com)

$220.00

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