Harford Soccer Camp, LLC harfordsoccercamp.com REGISTRATION FORM

Harford Soccer Camp, LLC
June 23 – 27, 2014 – The John Carroll School
(Please type or print legibly)
Last Name: ______________________________________ First Name: ____________________________________
 Female
 Male
Age at start of camp: ________
School: _________________________________
T-Shirt Size:  YS
Goalkeeper Training?  Y  N
 AS
 YM
 YL
 AM
 AL
Last Name: ______________________________________ First Name: ____________________________________
Home address: ____________________________________________________________________________________
City: ____________________________
State: _________________________ Postal/Zip Code: _______________
Home Phone: (
) __________________________________
Work Phone: (
) __________________________________
Cell Phone: (
) _________________________
Parent Email: _____________________________________________________________________________________
Name: ______________________________________ Relationship to Camper: _______________________________
Phone Number: (
) ________________________________
Physician Name: ________________________________ Physician Phone Number: (
) ____________________
Medical Insurance Company: _______________________________________________________________________
Insurance Policy Number: ___________________________________________________________________________
Insurance Company Address: ________________________________________________________________________
City: ____________________________
State: _________________________ Postal/Zip Code: _______________
Date of Last Tetanus Shot: __________________________________________________________________________
Allergies / Medications: _____________________________________________________________________________
Is your child on any medication?
 No  Yes
If Yes, please specify: ________________________________
Cost per camper
 Harford Soccer Camp - Boys and Girls, ages 5 - 17
9 am – 3 pm
$ 250.00
 Half-Day Clinic - Boys and Girls, ages 5 & 6
9 am – 11:30 am
$ 220.00
 Parent Seminar - Friday, June 27, 2013, 1 pm – 2 pm
(Topics covered: Athletic Training, Soccer in the Community, Rules/Regulations, etc)
 LT. Michael P. Howe Heroes Scholarship
The Harford Soccer Camp is proud of our country’s heroes! To show appreciation for our military
personnel, police officers and firefighters who have been killed in the line of duty, we provide full camp
scholarships to their soccer playing sons and daughters for a lifetime!
How did you hear about Harford Soccer Camp?
 Website
 Brochure
 Print Ad
 Road Sign
 Past Camper
 Referral: _____________________________________________________
You may register and pay online using PayPal at harfordsoccercamp.com (A 3% convenience charge will be applied for online payment).
PayPal offers the convenience of direct deposits from your checking account or use of any major credit card.
If you prefer, you may mail this completed registration form along with a check made payable to:
Harford Soccer Camp, LLC
Payment in full is due at time of application
P.O. Box 1351
All returned checks will be assessed a $25 additional charge
Bel Air, MD 21014
Drop off time: 8:45 am daily
Pick up time:
 11:30 am for half day clinic campers
 3 pm for full day campers
LUNCH: BRING YOUR OWN LUNCH! Small snacks and beverages will be available to purchase daily. Please be sure your child’s
lunch is clearly marked with their first and last name. Refrigerators will NOT be available for your child to store his/her lunch. Glass
bottles/containers are not allowed.
EQUIPMENT: Each camper is expected to provide his or her own equipment daily. This includes shorts, indoor shoes, soccer cleats,
sun block, and shin guards. Each camper will be given a camp T-shirt and a ball on the first day of camp.
REFUND POLICY: A $50 non-refundable administrative fee will be applied per camper.
Contact Information: For additional information, please contact:
Mark Giordano – Camp Director (410) 688 – 2830
Brian Gunter – Camp Director (443) 528 - 1711
I, __________________________________(parent/guardian), give my child, ___________________________________,
permission to participate in the Harford Soccer Camp, LLC. I have no knowledge of any physical or mental impairment
that would affect this camper from participating in the camp’s program. I give permission for my child to be given
emergency treatment at a local hospital if deemed necessary by the on-site medical staff. Upon signing, I agree that in
case of an accident while in the Harford Soccer Camp, LLC, I accept full responsibility for any and all liabilities, and
release Harford Soccer Camp, LLC, the camp directors and instructors, the John Carroll High School, or any recreational
facilities that may be used for camp from any liability. I hereby, by signature, acknowledge reading and understanding
the terms of this agreement and verify that my child is physically fit to participate in this event.
I also agree not to hold Harford Soccer Camp, LLC, responsible in the event that my child engages in inappropriate
conduct (including, but not limited to disruptive or volatile behavior, etc.) or becomes involved in any activity with any
persons not associated with Harford Soccer Camp, LLC, or its scheduled program. Harford Soccer Camp, LLC, has the
authority to send your child home for inappropriate conduct. I further attest that the information contained in this
application is correct to the best of my knowledge. In addition, I have agreed to the policy and fee statement and agree to
I hereby give permission for my child’s picture to be used by Harford Soccer Camp, LLC, for any educational or
promotional purposes.
Signature of Parent / Guardian: ______________________________________________
Print Name: _______________________________________________________________
Date: ____________________