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Athlete's name:___________________________ Parent's Name(s):_________________________ E-mail: _________________________________ Address:_______________________________ City:___________________________________ State/Zip:_______________________________ Home Phone:(_____)______________________ School & City:_____________________________ Grade: (08-09)____________________________ Age: ___________________________________ T-shirt size (Adult sizes--Please circle) YM YL S M L XL Circle which camp applies: June 9th-12th Grades 3-9
9:00am-12pm Please fill out the permission to treat form to the right and send this page with $50 (please make checks payable to NEWLHS Soccer Camp) to: NEW LHS SOCCER CAMP Questions? Please Call: Jeff Schaefer h-822-4421 s-469-6810 fax 469-2200 I look forward to seeing you at camp. God bless, Coach Schaefer |
Permission to Treat Form I authorize camp and/or school personnel to transport my son/daughter to a physician's office and/or emergency room for treatment in the event that emergency medical care is needed while s/he is involved in the NEWLHS Soccer camp. Further I authorize the PHYSICIAN and HOSPITAL STAFF to treat my son/daughter, as they deem necessary in the emergency situation. Parent/Guardian Signature: __________________________________ Date: _____________________________ Insurance Carrier: __________________________________ Policy #:___________________________ Known Allergies:_________________________ Medical Conditions and/or Medications _______________________________________ Father's Full Name: ________________________ Father's emergency phone:__________________ Mother's Full Name:_______________________ Mother's emergency phone:_________________ Family Doctor's phone:_____________________ Family Dentist's phone:_____________________
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