Name ___________________________________ E-mail _____________________

Emergency Phone __________________________________ Age ______ Sex F M

Street Address _____________________________________________________

City _______________________________________ State _______ Zip _______

School ___________________________________________________________

1. I am the parent (or guardian) of the above named child, who wishes to participate in the camp sponsored by the Headwaters Soccer Club.
2. It is my intention by this statement to grant my permission to the Headwaters Soccer Club to allow my child to participate and that I agree to assume risk for all injuries suffered by my child as a result of this participation in activities during the camp.
3. I also agree to indemnify and hold harmless the Headwaters Soccer Club and the participatin sponsors for any and all causes of action brought against the Headwaters soccer Club and the participating sponsors which are commenced by third persons alleging injuries, property damage or death arising from the acts of my child, whether negligent, malicious or intentional.
4. I hereby authorize the Directors of the Headwaters Soccer Club to act for me according to their best judgement in any emergency requiring medical attention.

_______________________________________________________________
Signature of Parent or Guardian Date
PLEASE CHECK:    
Session I
 o June 25 - 29 at Otego American Legion Post #1555
Session II
 o July 2 - 6 at Worcester Central School
NO REFUNDS DUE TO
INCLEMENT WEATHER
Session III
 o

July 9 - 13 at Mine Kill State Park
Session IV
 o July 16 - 20 at Mine Kill State Park
Session V
 o July 23 - 27 at Edmeston Central School
Session VI
 o July 30 - August 3 at Mine Kill State Park
includes goalkeeper session
Session VII
 o August 6 - 10 at Oneonta State
includes goalkeepers session

Cost: $60.00 per session with own ball; $75.00 with ball
Additional Donation Appreciated
On-site Registration: $10.00 additional charge.
If purchasing a ball, please indicate size: o #5 (Regulation) o #4 (Smaller)

Sign and return the completed application with a CHECK payable to:

HEADWATERS SOCCER CLUB
c/o Mine Kill State Park
P.O. Box 898, 1378 State Route 30
North Blenheim, N.Y. 12131

Please report at 9:15 A.M. the Monday morning of your session unless you are notified that the session was full when your application was received.

Goalkeepers Please Complete Reverse Side