XL NC Soccer Fusion College ID Camp
NC Soccer Fusion College ID Camp 2018 Registration Form **Space is limited. Please send full payment to secure your enrollment in this camp!
Name_________________________________ Age______ Address_________________________________________ City_______________________ DOB________________
State ___________
Grad Year______________
Please make checks payable to: NC Soccer Fusion Please mail checks to: GUSA PO Box 9185 Greensboro, North Carolina 27429 Attn: Fusion ID Camp Questions? Contact Adam Reekie Phone: 336-473-3411 Email: [email protected]
Parent/Guardian___________________________________ Phone (h)_______________
(cell)__________________
Email___________________________________________
Club Team_______________________________________
SELECT CAMP
SELECT PLAYING POSITION
□GK □Defender □Midfielder □Forward SELECT TSHIRT SIZE (All sizes are ADULT)
□SM □MD
□LG
□XL
□ GIRLS College ID Camp
□ BOYS College ID Camp
Saturday - Jan 20, 2018 Grades 8th – 12th $150 BB&T Soccer Complex at Bryan Park, Greensboro NC
Sunday - Jan 21, 2018 Grades 9th – 12th $150 BB&T Soccer Complex at Bryan Park, Greensboro NC
Medical Information: Insurance Company: ____________________________
Insurance Policy #: _____________________________
Any Medical Conditions staff should be aware of? _________________________________________________________ All campers must have Medical/Insurance information on file with the camp to participate. The camp provides only excess coverage after your insurance policy has been utilized. **No camper will be allowed to participate in camp activities until this information is provided to the NC Fusion staff and the waiver has been signed by a parent or guardian**
DISCLAIMER STATEMENT I/We, the undersigned, hereby certify that I (we) am (are) the parent of legal guardian of the camper. I hereby give permission for the staff of the Camp to seek, during the period of the Camp, appropriate medical attention and for the camper to receive medical attention in the event of any accident, injury, or illness. I will be responsible for any costs of medical attention and treatment, except for that covered by the camp’s excess medical policy. I/We, the undersigned, herby acknowledge and understand that the North Carolina Soccer Fusion Camp is a privately-run sports camp under the sole sponsorship, control, and supervision of NC Soccer Fusion. I/We, the undersigned, for ourselves our heirs, my personal representative, executors and administrators, hold harmless, waive, release and forever discharge the North Carolina Soccer Fusion and its trustees, directors, officers, agents, employees, representatives, successors and assigns from any and all liability, damages, claims, demands, actions, and cause of actions whatsoever arising out of or related to any loss, personal injury, or property damage that may be sustained or occur during participation in Camp/Clinic activities or while at Camp/Clinic, whether caused by the negligence of North Carolina Soccer Fusion or otherwise.
. Signature (Parent or Guardian) ___________________________________________________________
Date __________________________
PAYMENT/REFUND: Payment must be made in full to secure your enrollment in this camp. $50 of the registration fee is non-refundable. All cancellations must be received in writing 10 days prior to your camp date to qualify for a refund – less the $50 non-refundable fee. Failure to meet this deadline could result in forfeiture of all refund payments.
Name_________________________________ Age______ Address_________________________________________ City_______________________ DOB________________
State ___________
Grad Year______________
Please make checks payable to: NC Soccer Fusion Please mail checks to: GUSA PO Box 9185 Greensboro, North Carolina 27429 Attn: Fusion ID Camp Questions? Contact Adam Reekie Phone: 336-473-3411 Email: [email protected]
Parent/Guardian___________________________________ Phone (h)_______________
(cell)__________________
Email___________________________________________
Club Team_______________________________________
SELECT CAMP
SELECT PLAYING POSITION
□GK □Defender □Midfielder □Forward SELECT TSHIRT SIZE (All sizes are ADULT)
□SM □MD
□LG
□XL
□ GIRLS College ID Camp
□ BOYS College ID Camp
Saturday - Jan 20, 2018 Grades 8th – 12th $150 BB&T Soccer Complex at Bryan Park, Greensboro NC
Sunday - Jan 21, 2018 Grades 9th – 12th $150 BB&T Soccer Complex at Bryan Park, Greensboro NC
Medical Information: Insurance Company: ____________________________
Insurance Policy #: _____________________________
Any Medical Conditions staff should be aware of? _________________________________________________________ All campers must have Medical/Insurance information on file with the camp to participate. The camp provides only excess coverage after your insurance policy has been utilized. **No camper will be allowed to participate in camp activities until this information is provided to the NC Fusion staff and the waiver has been signed by a parent or guardian**
DISCLAIMER STATEMENT I/We, the undersigned, hereby certify that I (we) am (are) the parent of legal guardian of the camper. I hereby give permission for the staff of the Camp to seek, during the period of the Camp, appropriate medical attention and for the camper to receive medical attention in the event of any accident, injury, or illness. I will be responsible for any costs of medical attention and treatment, except for that covered by the camp’s excess medical policy. I/We, the undersigned, herby acknowledge and understand that the North Carolina Soccer Fusion Camp is a privately-run sports camp under the sole sponsorship, control, and supervision of NC Soccer Fusion. I/We, the undersigned, for ourselves our heirs, my personal representative, executors and administrators, hold harmless, waive, release and forever discharge the North Carolina Soccer Fusion and its trustees, directors, officers, agents, employees, representatives, successors and assigns from any and all liability, damages, claims, demands, actions, and cause of actions whatsoever arising out of or related to any loss, personal injury, or property damage that may be sustained or occur during participation in Camp/Clinic activities or while at Camp/Clinic, whether caused by the negligence of North Carolina Soccer Fusion or otherwise.
. Signature (Parent or Guardian) ___________________________________________________________
Date __________________________
PAYMENT/REFUND: Payment must be made in full to secure your enrollment in this camp. $50 of the registration fee is non-refundable. All cancellations must be received in writing 10 days prior to your camp date to qualify for a refund – less the $50 non-refundable fee. Failure to meet this deadline could result in forfeiture of all refund payments.
