2010
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 7-11: _____ Resident Camper _____ Day Camper
June 14-18: _____ Resident Camper _____ Day Camper
June 21-25: _____ Resident Camper _____ Day Camper
EARLY BIRD SPECIAL: Receive a $25 discount if registered by Feb. 15, 2010
One Week Residential: $500 One Week Day: $395
Two Weeks Residential: $970 Two Weeks Day: $760
Three Weeks Residential: $1,450 Three Weeks Day: $1125
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: _____________________________
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, 2010. All applications received after June 1, 2010 must include full payment. Any change request after June 1, 2009 will incur a $25 change fee. Returned checks will be charged a $25 fee. Make all checks payable to: 2010 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