2023 Youth Soccer Camp Registration

Parent/Guardian Information

Parent/Guardian Name

Parent/Guardian Email

This address will receive a confirmation email

Parent/Guardian Cell

Parent/Guardian Address

Camper Info

Camper Name

Camper Address [if different from parent/guardian]

Camper Gender

Camper Grade Attending in the Fall

Camper Age At Time of Camp

Camper Date of Birth

Camper Shirt Size

Camper Shirt Size if "Other" Above

How many years of playing experience does this camper have?

Does the camper have any known physical disability or illness which might interfere with their participation in strenuous activity

Yes No

Does the camper have any severe allergies or reactions to drugs or medicines?

Yes No

Does the camper have any severe allergies or reactions to specific food?

Yes No

Emergency Contact

Name

This address will receive a confirmation email

Cell

Relationship to Camper

Camper Insurance

Camper insurance company name

Camper insurance policy number

Camper insurance company phone number

Are camp staff authorized to approve medical treatment in the event of emergencies?

Yes No

Participation Agreement & Liability Waiver

I acknowledge that participation in the activity described above involves risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

In consideration for the opportunity to participate in the activity described above (the “activity”), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise.

If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association.

I give permission for my child to participate in this soccer camp with Renovation Church under these conditions.

Yes No

Registration Payment

Payment can be made online through this registration form or by check/cash in person or by mailing a check to Renovation Church, 118 Josephine Street, North Syracuse NY 13212. If choosing cash or check, make that selection in the drop-down below (default is online) to bypass the online payment. Payment must be made by Friday, June 14th to secure your spot in the camp.

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2023 Youth Soccer Camp Registration

Description

Please Fix the Following