For More Information:LGGSA18 Marjorie WayHamilton NJ 08690
Phone: 609-577-9382Email: lisapitt11@verizon.net
Parental Consent FormPlease Print and Sign
LGGSA Camps are for girls 6-14. Registration will be accepted until the camp start date if openings exist. Early mail-in registration is strongly recommended. Make all checks payable with completed forms to:
(Fully completed form must be submitted before camp participation)
Name _________________________________________________________
Birth Date _____________________________
Parent’s Day Time Phone Numbers:
Name_________________________________________Phone_______________
Emergency Contact Name___________________________________________
Phone_______________________________
Physician Name_____________________________________________________
Known Allergies_______________________________________________________________
______________________________________
Current Medication_______________________
Primary Health Insurance_______________________________________________________
Policy Number____________________________
Policy Holder____________________________
Secondary Health Insurance_____________________________________________________
Policy Number___________________________
Parent’s Authorization: I hereby certify that the above listed information is true. I understand that soccer is a physical sport. I represent that I have consulted with my child’s doctor and he/she concurs that my child is physically fit and mentally capable of participating in soccer and camp related activity. I hereby give permission for the camp staff to seek, during the times of camp, proper care for my child resulting from accidents, illness or injury. I will be responsible for the cost of any and all treatment except for that provided by the camp’s excess medical coverage policy. I, the undersigned, for myself, my heirs, executors and administrators, waive, release and forever discharge the camp, its entire staff and Mercer County Park, from all rights and claims for damages, injury or loss to personal property which may occur during camp, whether or not damages, injury or loss is due to negligence.