$25 per person

July 15-17

1 p.m.-2 p.m. | K-6th grades

Bring water, cleats, and shin guards

SOCCER CAMP 2020

505 ACADEMY ROAD | STARKVILLE, MS 39759 | PH: 662-323-7814 | FAX: 662-32305480

REGISTRATION FORM

STUDENT'S NAME

ADDRESS

STUDENT'S GENDER ENTERING GRADE

PARENTS' NAMES PARENTS' EMAIL

MOTHER'S CELL FATHER'S CELL

EMERGENCY CONTACT NAME & PHONE NUMBER METHOD OF PAYMENT (CASH OR CHECK) DATE OF PAYMENT

PARENTAL/GUARDIAN RELEASE:

I, (PARENT), CERTIFY THAT

(APPLICANT) IS IN GOOD HEALTH. I FURTHER CERTIFY, KNOWING THE CAMP WILL BE UNDER CLOSE SUPERVISION, THAT I WILL NOT HOLD STARKVILLE ACADEMY, ITS FACULTY OR THE DIRECTORS

OF THE CAMP RESPONSIBLE FOR INJURIES OR SICKNESS INCURRED BY MY CHILD DURING THIS CAMP.

SIGNED: DATE: