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Please print the form, complete and mail or fax to us
____ Ages 6 to 8 ~ $150 ____ Ages 9 & Up ~ $250 ____ August 11 - 14, 2008 ____ Ages 6 to 8 ~ $150 ____ Ages 9 & Up ~ $250 $25 late fee if registration is received after July 15th It is recommended that you email Info@bayareafutbol.com or call 408.394.4306 to reserve a spot to let us know to watch for your application as space is limited. To register for the camp, please print this page, complete the form and mail to P.O. Box 4768, San Jose, CA 95150 or fax to 408.877.1668. Make checks payable to Ian Russell Soccer. Sorry at this time we cannot accept credit card as payment. Player Information: Name:__________________________________________ Add:____________________________________________ City:____________________________________________ Email:______________________________________________ _____ State:______ Zip:__________ Tele #: (____) _______-___________ _____ Field Player _____ Goalie ~ Years Experience ________ Date of Birth ______/_____/______ Age ____________ Parent/Medical Information: Youth players provide: Mother: _________________________ Day Tele # (_____) ______-_________ Email:___________________________ Cell Ph # (______) ______-__________ Father: __________________________ Day Tele # (_____) ______-__________ Email:___________________________ Cell Ph# (______) _______-__________ Adult and Youth please provide: Emergency Contact:_________________________ Tele #: (_______) _______-___________ Physician Name: __________________________ Dr.’s Tele #: (_______) ______-_________ Please list any medical conditions:________________________________________ Insurance carrier:_____________________________ Group#:_______________ I give my approval for the above named player or myself to participate in any and all of the activities of the camps/clinics/training including but not limited to practices, drills, games and any other activity associated with the camps. PLAYER AND PARENTS ASSUME ALL RISKS AND HAZARDS INCIDENTAL TO THE CONDUCT OF THE ACTIVITIES AND TRANSPORTATION TO AND FROM THE CAMP. I further release, absolve, indemnify and agree to hold harmless Bay Area Futbol, Ian Russell, Ian Russell Soccer, Joe Cannon, the organizers, directors, sponsors, supervisors, coaches, facility, and administration and each of them from any claim, demand or action arising out of, or in any way related to the camp, including and not limited to any injury. In the event of an injury, I authorize the staff to obtain any medical care or treatment deemed necessary. I understand that soccer is very strenuous. I have had a physical and received medical approval before participating. I realize that there will be photographs taken during the camps. I agree to my (or my child’s) picture being taken and I agree to its use in advertising and in various promotional uses. I HAVE CAREFULLY READ THE ABOVE WAIVER AND RELEASE AND FULLY UNDERSTAND THIS IS A RELEASE OF LIABILITY AND I AGREE TO IT VOLUNTARILY. __________________________________SIGNATURE _______________ DATE
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