MIKE GETMAN SOCCER Day Camp APPLICATION 2008

Click here to Register Online! ($15 handling fee applies)

Name______________________________________________________________

Address_____________________________________________________________

City_____________________State____________Zip________________________

Home Phone__________________________________________

Parent’s Name_________________________________________

Parent’s E-Mail Address_________________________________

(we send your registration confirmation & information by email, so please print neatly)

Age at camp ___________________ Date of Birth ____________

Circle T-shirt size: YL   Adult:   S   M   L   XL

Indicate training you wish to receive at camp:     ___Field Player  or ___Goalkeeper

____Day Session I June 9 - 13 (at UAB) $215

____Day Session II July 7 - 11 (at JCC) $215

I heard about UAB Soccer Camp thru :

___I have been a past camper for_____ years   ___friend  ___brochure mailed

___my coach ___internet search ___newspaper ad code # ______

___other________________________________

___I have enclosed $25 to purchase a Nike soccer ball

A $50.00 deposit for each day camp session must accompany

this application.  After May 1st send full payment.

Application - Medical Information

Camper's Name___________________________  Date of Birth____________

Medical Insurance Company Name & Policy Number ____________________________

____________________________________________________________________

Emergency Phone Numbers

Father (home)___________________(work)________________(cell)_____________

Mother (home)___________________(work)________________(cell)_____________

In an emergency, if parents cannot be reached contact:

Name______________________________Relationship_________________________

Phone#______________________________________________________________

Family Doctor _____________________________ Phone # ___________________

Known Allergies______________________________________________________

Asthma __________________________

Diabetes ___________________________

Last Tetanus Shot or Booster ________________

List of Medications Currently Taking _______________________________________

__________________________________________________________________

I, the undersigned Parent/Guardian of the above named participant acknowledge that I understand and hereby consent as follows: 

I understand and acknowledge that there are some risks involved in participation, including but not limited to risk of physical injury, and that I agree to release and discharge the Mike Getman Soccer Camp, LLC. (Camp), its employees and agents and The Board of Trustees of the University of Alabama ("the Board"), The University of Alabama at Birmingham ("UAB"), their officers, directors, employees and agents from any and all liability, claims, demands and causes of action or other loss suffered by the participant in connection with participation in the camp excepting only liability, claims and expenses arising out of the sole negligence of the Mike Getman Soccer Camp, LLC., the Board, UAB or the officers, directors, employees and agents thereof.

I warrant and represent, to the best of my knowledge and belief, that the participant is healthy and able to participate in the Camp, and I agree to notify Camp administrators of any allergies or other physical, mental or emotional condition that might limit the participant's ability to safely participate  in the Camp activities.

I give permission to the Mike Getman Soccer Camp, LLC., its trainers or other staff members, agents and any attending physician to provide such emergency care and treatment to the participant as in their judgment may be deemed necessary or advisable in the event that the participant should require emergency care while participating in the Camp.  I agree to assume the costs of such emergency care and treatment, if any such costs are incurred.

_______________________________ _______________

Parent or Guardian Signature                    Date

Make Check Payable to: Mike Getman Soccer Camp, 313 Edgewood Blvd., Birmingham, AL 35209