Liberty Soccer Clinic 2011 Camp Fee $25

LIBERTY GIRLS SOCCER CLINIC DATES: 9/21-10/28

LOCATION: LIBERTY GYM (NEW)

***EVERY MONDAY & WEDNESDAY***

TIMES: 6:00-7:00 AM (EXCEPT FOR TWO WEEK BREAK)

TWO WEEK BREAK

TUESDAY & WEDNESDAY *** IN THE STADIUM***

8:00-9:30AM 9/29,9/30,10/6,10/7

COST: $25.00 ` CHECKS PAYABLE TO: LIBERTY GIRLS SOCCER

QUESTIONS: 925-634-3521 ext.5722 [email protected] LIBERTY SOCCER CLINIC 2015 – CAMP FEE $25

PLEASE PAY WITH CASH OR CHECK PAYABLE TO: LIBERTY GIRLS SOCCER

AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR (please print using blue or black ink) I/We the undersigned parent(s) of , ______, a minor, do hereby give permission for trainers and coaches of Liberty High School to seek emergency care for my/our child at a local medical facility if I/we cannot be reached in the event of illness or injury. It is understood that this authorization is given in advance of any specific diagnosis or treatment being required, and I/we will be contacted in the event of illness or injury as soon as possible. This authorization shall remain effective until Nov. 10, 2015, unless sooner revoked.

______Parent/Guardian Signature Date Phone Number

PERSON TO NOTIFY IF PARENT/GUARDIAN NOT AVAILABLE

Person to notify / Relation to Camper ______

Day Phone / Evening Phone ______

MEDICAL INSURANCE CARRIER

Insurance Company Group/Account number ______

I.D. Number Insurance Phone Number ______

RELEASE OF LIABILITY I/we the parent/guardian of the aforementioned child, hereby give permission for my/our child to participate in the 2015 Liberty Soccer Clinic. I/we understand there are obvious known dangers/risks inherent in the participation in this program, including but not limited to injuries sustained through a fall or contact or loss of personal property, and I/we voluntarily agree to assume such risks. In consideration of Liberty permitting my child’s participation in the camp, based on my reputation that my/our child is in proper physical health and condition to participate, I agree: 1. To assume all risk of injury to my child and all risk of damage to or loss of my child's property arising from my child's participation in the camp. 2. To release and forever discharge Liberty Soccer, its employees and coaches, from any and all claims or liability for any injury including death, and for property damage or loss which may be suffered by me or my child arising out of or in any connection with my child’s participation in the camp. I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN THE CLINIC AND MYSELF, ON BEHALF OF MY/OUR CHILD, AND I SIGN OF MY OWN FREE WILL.

Parent/Guardian Signature: ______Date:______

Full name of parent/guardian (please print): ______

Full address of parent/guardian (please print): ______

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