West Chester University Girls Soccer Winter Camp
West Chester University Girls Soccer Winter Camp Saturday December 3,2016 Location: West Chester Soccer Complex
Winter Camp For: FORWARDS, MIDFIELDERS, DEFENDERS, & GOALKEEPERS
Time :
12:30pm — 3:30 pm
Ages:
Soph, Juniors, Seniors and Transfers ONLY
Cost:
$100.00 registration fee
Betty Ann Kempf-Townsley—Head Coach Please make checks payable to:
West Chester University Women’s Soccer
PSAC Coach of the Year NSCAA Regional Coach of the Year Former NCAA DI Coach
Sheldon Chamberlain—Assistant Coach Pennsylvania Sports Hall of Fame Inductee Former NCAA DI Coach Won NAIA National Championship
Featuring the 2015 WCU Women’s Soccer Team **********************************************Registration Form**************************************************** Name: __________________________________________________________ Age: _________ Position:___________________________ Address: _____________________________________________ City:________________________ State: ________ Zip: ___________ Current School: ________________________________________ Current Grade: _______________________ Graduation Year: ________ Home Phone #: _________________________________________ Cell #: ____________________________________________________ EMAIL ADDRESS: ________________________________________________________________________________________________ Emergency Contact (Name/Phone): ___________________________________________________________________________________
ALL PARTICIPANTS should bring sneakers, cleats/turfs (for outside), shin guards, snack, drink and Waiver Form. Mail Checks (made payable to West Chester University Women’s Soccer)/Waiver/Registration Forms to: West Chester University Women’s Soccer Attn: Shelley Gabries Department of Athletics—Sturzebecker Health Science Center West Chester, PA 19383
West Chester University Girls Soccer Winter Camp Waiver Form—Liability/Medical Release I/we the parent(s) of _______________________, hereby give my/our approval to her participation in any and all WCU Girls Soccer Winter Camp activities. I/we do hereby waive, release, absolve, indemnify and agree to hold harmless the clinic/camp, its Director(s), coaches, WCU team members, and West Chester University. I/we grant permission for her to participate in the soccer clinic/camp and acknowledge that she is physically able to participate in clinic/camp activities. I authorize the organizers of the WCU Girls Soccer Winter Camp to act for me according to their best judgment in any case of emergency requiring medical attention. I accept full responsibility for liability and cost of treatment for above registered person.
Insurance Carrier: ____________________________________ Policy/Group #: ______________________________________ Parent Signature: ____________________________________ Emergency #: _______________________________________ Date: ______________________________________________ Please describe any important emergency information or physical disability on back of this form. Also indicate if participant is taking any medication or has an adverse reaction to any medication. Please indicate if religious beliefs prevent or limit medical attention and what care may be provided.
Mail Checks (made payable to West Chester Women’s Soccer)/Waiver/ Registration Forms to: West Chester University Women’s Soccer Attn: Shelley Gabries Department of Athletics—Sturzebecker Health Science Center West Chester, PA 19383
Winter Camp For: FORWARDS, MIDFIELDERS, DEFENDERS, & GOALKEEPERS
Time :
12:30pm — 3:30 pm
Ages:
Soph, Juniors, Seniors and Transfers ONLY
Cost:
$100.00 registration fee
Betty Ann Kempf-Townsley—Head Coach Please make checks payable to:
West Chester University Women’s Soccer
PSAC Coach of the Year NSCAA Regional Coach of the Year Former NCAA DI Coach
Sheldon Chamberlain—Assistant Coach Pennsylvania Sports Hall of Fame Inductee Former NCAA DI Coach Won NAIA National Championship
Featuring the 2015 WCU Women’s Soccer Team **********************************************Registration Form**************************************************** Name: __________________________________________________________ Age: _________ Position:___________________________ Address: _____________________________________________ City:________________________ State: ________ Zip: ___________ Current School: ________________________________________ Current Grade: _______________________ Graduation Year: ________ Home Phone #: _________________________________________ Cell #: ____________________________________________________ EMAIL ADDRESS: ________________________________________________________________________________________________ Emergency Contact (Name/Phone): ___________________________________________________________________________________
ALL PARTICIPANTS should bring sneakers, cleats/turfs (for outside), shin guards, snack, drink and Waiver Form. Mail Checks (made payable to West Chester University Women’s Soccer)/Waiver/Registration Forms to: West Chester University Women’s Soccer Attn: Shelley Gabries Department of Athletics—Sturzebecker Health Science Center West Chester, PA 19383
West Chester University Girls Soccer Winter Camp Waiver Form—Liability/Medical Release I/we the parent(s) of _______________________, hereby give my/our approval to her participation in any and all WCU Girls Soccer Winter Camp activities. I/we do hereby waive, release, absolve, indemnify and agree to hold harmless the clinic/camp, its Director(s), coaches, WCU team members, and West Chester University. I/we grant permission for her to participate in the soccer clinic/camp and acknowledge that she is physically able to participate in clinic/camp activities. I authorize the organizers of the WCU Girls Soccer Winter Camp to act for me according to their best judgment in any case of emergency requiring medical attention. I accept full responsibility for liability and cost of treatment for above registered person.
Insurance Carrier: ____________________________________ Policy/Group #: ______________________________________ Parent Signature: ____________________________________ Emergency #: _______________________________________ Date: ______________________________________________ Please describe any important emergency information or physical disability on back of this form. Also indicate if participant is taking any medication or has an adverse reaction to any medication. Please indicate if religious beliefs prevent or limit medical attention and what care may be provided.
Mail Checks (made payable to West Chester Women’s Soccer)/Waiver/ Registration Forms to: West Chester University Women’s Soccer Attn: Shelley Gabries Department of Athletics—Sturzebecker Health Science Center West Chester, PA 19383
