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2012 WINTER MINI CAMP APPLICATION

Name:
Address:
Phone:
Email:
First Time LDGA Camper:
If Yes, Recommended By:
Gender:
Age:
High School:
High School Graduating Year:

Parent/Guardian Name:
Payment Type:
Consent:
I hereby permit my child to participate in the Last Defense Goalkeeping Academy camp/ Goalie War tournament conducted by Ron Apollon, Hope H. Clark and its staff. By the execution of this release, I acknowledge and agree that all requirements, directions, supervision, and standards set by the directors of this program shall be established for his/her benefit. I hereby voluntarily assume all risk of accident or injury to my child which may arise out of his/her participation in this program, hereby intending to release all personnel associated with this program from liability that may result from his/her participation. In addition, I hereby give my permission for emergency medical treatment in the event I cannot be reached.
I consent to the terms above:
Parent/Guardian Name:
Agreement Date:
Camper's Name:
Emergency Contact:
Emergency Phone #(s):
Relationship:
Insurance Carrier:
Policy Number:
Physician:
Physician Phone #:
Known Allergies:

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