Athens High School Summer Camp

Session 1: June 15 18th (4th 9th grade for fall of 2015)

Session 2: July 13th 16th (4th 9th grade for fall of 2015)
Session 3: July 20th 24th (High School 9th 12th grade)
REGISTRATION FORM
PARTICIPANT INFORMATION

Please type or print legibly.

Last Name:
Gender: Female

First Name:
Male

Age: ___________

___________

T-Shirt Size: S M L - XL

Home address:
City:

State/Province:

Telephone:

cell:

Postal/Zip Code:

Guardian email:
Guardians name:
Guardians cell:
Emergency contact*:

_________________
Relationship:

Phone:

Specify any of your childs health problems:

Is your child on any medication? No Yes If so, please specify:
Camp Details:
Participants will receive soccer instruction at a level that will both challenge them and ensure they have a
fantastic experience at soccer camp. Participants will be split by age groups. Coaches and Volunteer
Soccer Staff will cover different soccer topics and themes each day. Players will learn various soccer skills
and techniques of the game and have scrimmage time in order to put into practice everything they have
experienced.
Payments: Tuition may be paid by cash or by check. Make the check payable to: Athens HS Soccer
Due Dates: Session 1: Pay by June 2nd / Session 2: Pay by July 2nd / Session 3: Pay by July 16th
You may sign up on the first day of camp as well but you are not guaranteed a shirt or soccer ball
Camp Fees:
60$ is the cost of the camp for one session. The fee includes a soccer ball and a t-shirt for all
athletes. If multiple family members are signed up, each person will be at a starting cost of 50$.
If you do more than one session, the following sessions will cost 40$ per person (does not include
a ball or shirt). The money will go toward the Athens HS Soccer Team for equipment, end of the
year banquets, and a sound system for the soccer field.
Contact Information
For more information, contact Josh Ruben, at 815-382-8891 or e-mail jrubes.teach@gmail.com
SIGNATURE OF PARENT OR GUARDIAN

DATE

DROP OFF AND PICK UP TIMES

Drop off time: 3:45 - 4:00 pm
Pick up time: 6:00 pm
REQUIRES PARENTS SIGNATURE:
You have our permission, in the event of an emergency and in case we are unavailable, to authorize any
physician, nurse practitioner or medical personnel to examine, interview, test and if necessary, treat my
child_______________________________________________ as they may deem advisable.
Parent/Legal guardian name________________________________________________Date_______________
Parent/Legal guardian Signature_____________________________________________Date_______________
Student Allergies________________________________________________________________
Student Medical Problems_______________________________________________________________
Doctor______________________________Phone number____________________________________
Insurance carrier______________________Policy number______________________________________

I hereby give permission to Athens HS Soccer, to photograph and/or videotape the student for
educational or promotional purposes. ________ (Initial)
PARENT STATEMENT
I hereby state that (campers name) ___________________________________________ is in good mental and physical
health condition to participate in the activities provided by Athens HS Soccer, including but not limited
to all aspects of soccer and or competition. I am fully aware that any activity involving motion, height or
athletic activity creates the possibility of serious injury. I hereby release Athens HS Soccer, its
employees and its staff from liability to the above named athlete, of the person claiming through
him/her, arising from injury to the person or property of the above named athlete occurring in the
premises of Athens HS Soccer, Athens Soccer Field, including any event sponsored or sanctioned by
Athens HS Soccer, and or travel to and from such activities.
I understand that Athens HS Soccer, has the right to deny admittance to any student not meeting the
standards of the program as it sees fit. I also agree not to hold these parties responsible in the event that
my son/daughter/child engages in inappropriate conduct (including, but not limited to disruptive or
volatile behavior in or out of camp, etc.) or becomes involved in any activity or with any persons not
associated with Athens HS Soccer, or its scheduled program and that Athens HS Soccer, has the right to
send him/her home for inappropriate conduct. I further attest that the information contained in this
application is correct to the best of my knowledge. In addition, I have agreed to the policy and fee
statement and agree to comply.
Parent Signature_____________________________________________Date___________