Phoenix football Camp 2015 Registration Form

Please fill out the following information and return to:


FC Phoenix LLC

3637 E. Sunnyside Dr.
Phoenix Arizona 85028


Name of Player_________________________________
Age _____ DOB___________
Team _____________________________
Player Email _______________________________

Parents__________________________________Email________________________________

Street________________________________________ Town ______________ Zip ________

Home phone ___________________ Work ____________________ Cell ________________

 

Total amount  _________  (Group One)

Registration will not be processed without full payment. Receipt of such payment certifies that the applicant (applicant’s parent/guardian) has read and understands the Football Camp Phoenix policies in regard to medical attention, liability, medical expenses, personal items, refunds and cancellations and that a parent/guardian signature will accompany the Football Camp Phoenix registration form attesting thereto.
Deposit and registration fees can be paid online, or mailed to our address above .Checks need to be payable to FC Phoenix LLC.

Fathers name:______________  Phone:__________________
Mothers name: ________________  Phone:__________________
Legal Guardian:___________________  Phone:___________________
List any medical problems or prohibition of player ____________________________________________________
Person to notify in emergency:_______________________  Phone:_________________________
Doctor to notify in emergency:________________________  Phone:__________________________
Health Insurance Company name :___________________________________

IMPORTANT

Agreement
I, the parent /guardian of the below-named player, a minor, agree that I and the player will abide by the rules and regulation of the Football Camp Phoenix, Arizona. In consideration of the players participation in the soccer programs and activities of the FC Phoenix Parties, I, for myself and player and our respective heirs, administrators and successors, intending to be legally bound, hereby release and indemnify the FC Phoenix parties, the owners and operators of the facilities used for the Programs, and their respective directors, coaches, trainers, employees, agents, and representatives from and against all claims, liabilities, damages or causes of action arising out of or in connection with the players participation in the Programs including, without limitation, players transportation to/from and Program, which transportation is hereby authorized. I further grant the FC Phoenix Parties right to use the players name, picture and/or likeness in printed, broadcast and other material concerning the Programs provided such use is related to the players status as a participant in the Programs.
Name: ________________________  Player: __________________________


Signature:______________  Date: ____  Signature: _________________  Date: ______  

Consent of Medical Treatment
As the parent of legal guardian of the above named player, I hereby give consent for emergency. Medical care prescribed by a duly licensed Doctor of Medicine or Doctor of dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependant.
Signature of parent or legal guardian: __________________
Address:______________ City:__________ State:________ Zip:______
Phone:___________  work phone:_____________
Name of the insurance company:____________________
Group/Policy number: __________________________