Coach Sam LLC
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Camp Registration Form

Registration for Mighty Kicks Youth Soccer Camp
Please return no later than June 2, 2014

Camper:   ____________________________________________________

Age:   _________ Grade:  __________    Male:  _____  Female:  ______

Mother:  __________________________          Father:  ____________________________
Address:   __________________________       Address:  ___________________________
  __________________________                                       ___________________________
City:  __________________________               City:  ______________________________
State:    __________  Zip:  ___________           State:  ____________  Zip:  ____________
Home Phone:  ________________________     Home Phone:  _______________________
Work Phone:  _________________________    Work Phone:  _______________________
Cell Phone: ___________________________   Cell Phone:  _________________________
E-Mail:  ___________________________          E-Mail:  ____________________________

Location:   Soccer Oval at Chartiers Valley Intermediate School in Scott Township
Dates:   June 9 - 12, 2014
Time:   6:00 pm – 8:00 pm
Please Bring:  Water bottle, soccer ball, shin guards
Emergency contact in case parents can’t be reached:
Name:   ___________________________   Phone:  ____________________________
Relationship:   ___________________________
Please note any medical conditions or allergies we should be aware of:

I, the undersigned parent or guardian of this camper consent to enroll my child in this camp.  I certify that my child is in excellent health and may participate in strenuous activities, such as soccer.

I understand that campers must have their own medical coverage.  I also consent to have a medical provider give my child appropriate emergency medical assistance/treatment and agree to be responsible financially for the reasonable cost of such assistance/treatment.

I release, discharge, and / or otherwise indemnify the camp director, camp staff, and owners of fields and facilities used for the camp against any claim by or on behalf of my child as a result of my child’s participation in this camp.
____________________________________ ______________
Signature of Parent or Guardian                        Date

Camp fee is $75.00 if paid before May 1, or $80.00 if paid after May 1.  Please mail registration form and check, payable to “Coach Sam LLC” to:
Address:    Sam Bellin, 1147 Lindsay Road, Carnegie, PA 15106
Telephone: 412 – 867 6724 or E-Mail:

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