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Lisa Gmitter Girls Soccer Academy

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Registration Form

For More Information:
LGGSA
18 Marjorie Way
Hamilton NJ 08690

Phone: 609-577-9382
Email: lisapitt11@verizon.net

Players First Name:
Player's Last Name:
Players Age:
Address Street 1:
City:
Zip Code:	(5 digits)
State:
Parents Name:
Daytime Phone:
Parents Cell:
Fall 2008 School & Grade:
Email:
Player's Background	Enter comments here!

Parental Consent Form

Please 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_____________________________________________________

Phone_______________________________

Known Allergies_______________________________________________________________

______________________________________

Current Medication_______________________

Primary Health Insurance_______________________________________________________

Policy Number____________________________

Policy Holder____________________________

Secondary Health Insurance_____________________________________________________

Policy Number___________________________

Policy Holder____________________________

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.

Parent/Guardian Signature Date