Sponsored by:

www.TeamClinic.com

Soccer International / Cal Custom,
Santa Clara CA

Please print the form, complete and mail or fax to us             

____ July 28 - 31, 2008   cancelled      
____ Ages 6 to 8   ~ $150
____ Ages 9 & Up ~ $250

____ August 11 - 14, 2008       
____ Ages 6 to 8 ~ $150
____ Ages 9 & Up ~ $250

$25 late fee if registered after July 15th

 It is recommended that you email Ian@ianrussellsoccer.com or call 408.394.4306 to reserve a spot to let us know to watch for your application as space is limited.

To register for the camp, please print this page, complete the form and mail to P.O. Box 4768, San Jose, CA 95150 or fax to 408.877.1668. Make checks payable to Ian Russell Soccer.  We apologize that we cannot accept payment via credit card.

Player Information:

Name:__________________________________________

Add:____________________________________________

City:____________________________________________

Email:___________________________________________________

State:______ Zip:__________ Tele #: (____) _______-___________

_____ Field Player _____ Goalie ~ Years Experience ________

Date of Birth ______/_____/______ Age ____________

Parent/Medical Information:

Youth players provide:

Mother: _________________________ Day Tele # (_____) ______-_________

Email:___________________________ Cell Ph # (______) ______-__________

Father: __________________________ Day Tele # (_____) ______-__________

Email:___________________________ Cell Ph# (______) _______-__________

Adult and Youth please provide:

Emergency
Contact:_________________________ Tele #: (_______) _______-___________
Physician
Name: __________________________ Dr.’s Tele #: (_______) ______-_________

Please list any medical conditions:________________________________________

Insurance carrier:_____________________________ Group#:_______________

I give my approval for the above named player or myself to participate in any and all of the activities of the camps/clinics/training including but not limited to practices, drills, games and any other activity associated with the camps. PLAYER AND PARENTS ASSUME ALL RISKS AND HAZARDS INCIDENTAL TO THE CONDUCT OF THE ACTIVITIES AND TRANSPORTATION TO AND FROM THE CAMP. I further release, absolve, indemnify and agree to hold harmless Ian Russell, Joe Cannon, Ian Russell Soccer, the organizers, directors, sponsors, supervisors, coaches, facility, and administration and each of them from any claim, demand or action arising out of, or in any way related to the camp, including and not limited to any injury. In the event of an injury, I authorize the staff to obtain any medical care or treatment deemed necessary. I understand that soccer is very strenuous. I have had a physical and received medical approval before participating.  I realize that there will be photographs taken during the camps.  I agree to my (or my child’s) picture being taken and I agree to its use in advertising and in various promotional uses.
I HAVE CAREFULLY READ THE ABOVE WAIVER AND RELEASE AND FULLY UNDERSTAND THIS IS A RELEASE OF LIABILITY AND I AGREE TO IT VOLUNTARILY.

__________________________________SIGNATURE _______________ DATE

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