Summer Camp Application

2009 Summer Camp Application

Please contact Coach Andre Luciano for more information (928) 523-2021

Type of Camper
Camper First Name
Camper Last Name
Camper Address
Camper City
Camper State
Camper Zip Code
Grade (Fall 2007)
Age
T-Shirt Size
Purchase Camp Ball	No Yes - (additional $30.00 charge)
Parent First Name
Parent Last Name
Parent Address
Parent City
Parent State
Parent Zip Code
Parent Phone	(Area Code) and Number please.
Parent Evening/Emergency Phone	(Area Code) and Number please.
Parent Email (for Enrollment confirmation)
Insurance Company
Policy Holder Name
Policy Number
Insurance Company Address and Phone
Past Injuries
Current Health (medications)
Drug Sensitivities
Other Allergies

I certify to the best of my knowledge the statements included are accurate and that my child has permission to participate in the activities of the NAU Soccer Camp. I grant permission to the director, assistants, or other persons responsible for his/her care to act on my behalf for said minor in granting permission for evaluation and treatment of medical problems. I understand that should a major medical problem arise, an attempt will be made to notify me by telephone. In the event that I cannot be reached, I hereby give my consent to such treatment as deemed necessary (including surgery, X-ray examinations and anesthesia to be rendered to said minor by a licensed physician, nurse or qualified Health Care provider.) Also for said minor in transporting he/she by whatever means are necessary, to any health facility.
I agree with the statement above (please enter your initials)