Premier Soccer Academy
Franklin Square Raiders Summer Soccer
Camp 2010
www.premiersocceracademyusa.com
Household Information:
Last Name ______________________________________
Mother’s Name __________________ Father’s Name ___________________
Mother’s Maiden Name _____________________________________________
E-mail __________________________________________________________
Phone ___________________________________________
Address ____________________________________________
Player One Information:
First: ______________________ Last ____________________________
Date of Birth _____________________ Gender ____________________
Grade as of September _______ School ___________________________
Soccer Experience
____________________________________________
Player Two Information:
First: ______________________ Last ____________________________
Date of Birth _____________________Gender ____________________
Grade as of September _______ School ___________________________
Soccer Experience ____________________________________________
Full Day Camps:
|
August 2- August 6 |
Tully Park, New Hyde Park |
9am - 4pm |
$190.00 |
|
August 16- August 20 |
Tully Park, New Hyde Park |
9am - 4pm |
$190.00 |
All full day camps offer extended hours from 8am- 9am and 4pm-5pm. The cost is $12 per day per child.
Half day camps:
|
August 2 - August 6 |
Tully Park, New Hyde Park |
9am - 12pm |
$120.00 |
|
August 16 - August 20 |
Tully Park, New Hyde Park |
9am - 12pm |
$120.00 |
Mail form with payment to:
Franklin Square Raiders Soccer Club
PO Box 2810
Franklin Square, NY 11010
Payments to be written to: Premier Soccer Academy
Recognizing the possibility of physical injury associated with soccer and in consideration for Premier Soccer Academy and it’s affiliates accepting the registrant for its soccer programs and activities I hereby release, discharge and/or otherwise indemnify Premier Soccer Academy, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the programs, against any claim by or on behalf of the registrant’s participation in the programs and/or being transported to or from the same, which transportation I hereby authorize. My child has received a physical examination by a physician and has been found physically capable of participating in the programs.
Signature: _______________________________________ Date: _____________