2008
Preston Goldfarb's
"Excellence Through Fundamentals"
Birmingham-Southern College
Soccer Camp

Name ______________________________________________________

Address ____________________________________________________

City _________________________ State _________  Zip ____________

Home Phone # ______________________Cell Phone #__________________________

E-mail address _______________________________________________

Birthdate _____________________ Age _________  Sex _________________________

Position (check one):   Field __________________ Goalkeeper _____________________

Team/Player (s) to be grouped with:_____________________________________________

If new camper, how did you hear about the camp? _________________________________

High School/Club Team ______________________________________

Parents Name _______________________________________________

Work Number _______________________________________________

Roommate Preference ________________________________________

Status: Check Week or Multiple Weeks Desired
June 9-13:      _____ Resident Camper _____ Day Camper   
June 16-20:      _____ Resident Camper _____ Day Camper  
June 23-27:      _____ Resident Camper _____ Day Camper

EARLY BIRD SPECIAL: Receive a $25 discount if registered by Feb. 15, 2008

One Week Residential: $475                  One Week Day: $375
Two Weeks Residential: $920                Two Weeks Day: $720
Three Weeks Residential: $1,365          Three Weeks Day: $1065

Check T-Shirt Size (Adult Sizes): _____S  _____M  _____L  _____XL

Parental Consent

All areas of this form must be completed and signed prior to camp participation.

Camper’s Name: _____________________________
Social Security: ______________________________
Birth Date: _________________________________
Guardian’s Name: ___________________________
Relationship: _______________________________
Allergic Reactions: Yes ______ No ______
If yes, list: _________________________________
Taking medications: Yes ______ No ______
If yes, list: _________________________________

In Case of Emergency
Father home phone: ________________________
Father work phone: _________________________
Mother home phone: ________________________
Mother work phone: _________________________
Other Emergency Contact: ____________________
Phone Number: ____________________________
Your Insurance Company: ____________________
Policy #: __________________________________
Name of Policy Holder: _______________________________________
Any instructions regarding your insurance? ________________________ __________________________________________________________

I/We, the undersigned hereby certify that I (we) am (are) the parent or legal guardian of the camper. I herby give permission for the staff of the Camp to seek during the period of the Camp appropriate medical attention for the camper and for medical attention to be given to the camper in the event of accident, injury, or illness. I will be responsible for any and all costs of medical attention and treatment, except for that covered by the camp’s excess medical coverage policy. I/We understand that, as with any sport, injuries can occur and that our child is physically fit and mentally capable of participating in soccer and camp activities. I/We represent that I/We have sought the opinion of our child’s pediatrician _______________________ _______________ (pediatrician’s name) and he/she concurs that _______________________ (camper’s name) is fully capable of safely engaging in these activities. I/We, the undersigned for ourselves, our heirs, executors and administrators, waive, release and forever discharge the Preston Goldfarb's Excellence Through Fundamentals Birmingham-Southern College Soccer Camp and its staff and representatives and assign of and from all rights and claims for damages, injury, or loss to person or property which may be sustained or occur during participation in Camp activities or while at Camp.

_________________________________________ _________
Signature of Parent or Guardian Date

Please fill out the entirety of this form and return it with your deposit to reserve your space at camp

A $100.00 non-refundable deposit must accompany each application with the balance of the camp fee to be paid before June 1, 2008. All applications received after June 1, 2008 must include full payment. Any change request after June 1, 2008 will incur a $25 change fee. Returned checks will be charged a $25 fee. Make all checks payable to: 2008 Preston Goldfarb's BSC Soccer Camp.

For Official Use Only

Deposit _______ Date _______ Ck # _______ Balance _______
F. Pmt. _______ Date _______ Ck # _______

Print application and return with deposit to:

Preston Goldfarb, Head Soccer Coach
Birmingham-Southern College
Arkadelphia Road, Box 549035
Birmingham, AL 35254