Scorpions Residential

New England Super Camp

Scorpions Residential Camp Information

Date: July 20-24, 2009

Location: Bridgewater State College

Cost: $375, check made out to Scorpions Soccer Club

How to sign up: 1) Fill out the registration form below!
2) Mail payment to Keith Caldwell,
290 Tremont St, Braintree MA 02184

Questions? Contact:

Keith Caldwell, Director of Coaching: keith@socceredge.org
Fred Marks, Club Director: scorpionssoccer@aol.com

New England Super Camp Registration Form

Notes: Scroll down to complete entire form; Leave signature blank for when you arrive at camp!

Player Name:

Parent/Guardian Names:

Phone (House):
      (Cell):

Player Team:
Player Birthdate:
T-Shirt Size:

Player Address:

Email Address:

Residential/Commuter?

Roommate Request:

MEDICAL RELEASE INFORMATION
As the parent/legal guardian of the above-named player, I request that in my absence the above-named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named player.

Date of last Tetanus Booster:

Known Allergies of this player, including any allergies to medicine:

Any other medical problems which should be noted:

Any medications the player will be required to take during the camp?  If so, give exact details on what medicine and how often:

Family physician:
Family physician phone:

Person to notify in case of emergency (in case parent or guardian is not available):
Emergency contact phone number:

GENERAL LIABILITY INFORMATION
Recognizing the possibility of physical injury associated with soccer and in consideration for the Scorpions accepting the
registrant for its soccer programs and activities, I hereby release, discharge and/or otherwise indemnify the Club (South
Coast Scorpions Soccer Club, Inc., doing business as ‘Scorpions Soccer’), their employees and associated personnel
against any claim by or on the behalf of the registrant as a result of the registrant's participation in the soccer camp.

Signature of parent/guardian:

Date: