Registration for Total Soccer High School Academy
Please return no later than June 17, 2020
Player: ____________________________________________________
Age: _________ Grade: __________ Position:_______________________
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 Schenley Oval in Squirrel Hill
Dates: June 22 - 25, 2020
Time: 6:00 – 8:00 pm
Please Bring: Water bottle, soccer ball, shin guards, Green Shirt, White Shirt
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
Program fee is $100.00. Please mail registration form and check, payable to “Mighty Kicks” to:
Address: Sam Bellin, 1147 Lindsay Road, Carnegie, PA 15106
Telephone: 412 - 867 - 6724 or E-Mail: samb4@comcast.net