JC Soccer Elite Winter Camp for Girls
Registration Form
Transportation
Refunds
Each camper is responsible for her own
transportation to and from camp.
Lynchburg Regional Airport is serviced by
US Air and Delta. The bus service is Greyhound (1-800-231-2222). Arrangements for
pick-ups and drop-offs need to be expressed
to Ethan Allen (Camp Director) at 434-5822389 or at [email protected]
Should you have an unfortunate circumstance and have to cancel your attendance, please do so before February 11th,
2011. A $50 administrative fee will be
deducted from your deposit. No refunds
will be issued once camp begins.
Camper Information:
Name______________________________
D.O.B._____________________________
Rules & Regulations
Individuals are required to comply with
the rules & regulations of Liberty University and the Liberty Lady Flames
Women’s Soccer Camp. A copy of these
rules will be sent to you in a registration
package upon receipt of your application.
Any camper who does not abide by these
rules may be dismissed without refund.
Parental Consent Form This completed form will enable health facilities in
Lynchburg and camp medical staff to provide
prompt care to your minor son or daughter. All
areas of this form must be completed prior to
camp registration. I/We, the undersigned, hereby
certify that I/we am/are the parent or legal guardian of the camper. I hereby give permission for the
staff of the camp to seek, during the period of the
camp, appropriate medical attention for the
camper, and for medical attention to be given, and
for the camper to receive medical attention in the
event of accident, injury, or illness. I/we will be
responsible for any and all cost of medical attention and treatment. I/We, the undersigned, for
ourselves and as a guardian(s)
T-Shirt Size_________________________
___________________________________
___________________________________
Insurance company__________________
Agent’s
name______________________________
Of ____________________________ (camper’s
name) understand that soccer is an active, physical
sport, and that injuries can take place during play.
I/We understand that, as with any sport, injuries
can occur, and we hereby admit that our child is
physically and mentally capable of participating in
soccer and camp activities. I/We represent that I/
We have sought the opinion of our child’s pediatrician, ___________________, and he/she concurs
that, __ _____________ is fully capable of safely
engaging in these activities. I/We also understand
that it is my/our responsibility in caring for the
camper listed above, to be assured that he/she is
fully capable of engaging in this sports activity, and
I/we are confident that he/she is able to engage in
such sport. I/We, the undersigned, for ourselves,
our heirs, executors and administrators, waive,
release and forever discharge Liberty Women’s
Soccer Camp, the Liberty University soccer
coaches, officers, agents, employees, representatives, successors and assign of and from all rights
and claims for damages, injury, or loss to person or
property which may be sustained or occur during
participation in camp activities or while at camp,
whether or not damage, injury, or loss is due to
negligence.
Policy #_______________
Signature of parent or guardian
Phone #________________
______________________________________
Any instructions regarding your insurance?
Date
______________________________________ Grad. Year _________________________
Address
___________________________________
___________________________________
___________________________________
Medical Info
Camper’s physician / Phone number
Email______________________________
Home Phone________________________
Emergency Phone____________________
Parent(s) / Guardian (s)
___________________________________
Preferred Position____________________
Club
Team______________________________
Residential Camper? _________ $125.00
Commuter Camper? _________ $75.00
*Campers whose parents are driving them to
camp and staying in town can reserve hotel
rooms at the Days Inn under the JC Soccer
Camp Block of Rooms. Call 434-847-8655
to make reservations.
___________________________________
Date of last tetanus toxoid:____________
Allergic reactions?:___________________
Medication presently taking:
___________________________________
Past illnesses or information that would
be useful in the event of necessary treatment:
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Please fill out the application and parental consent form and return it with the camp fee to reserve your space at camp. Please make check out to “JC Soccer Camp.” Mail to: Liberty University Attention: Women’s Soccer 1971 University Boulevard Lynchburg, VA 24502 JC Soccer Elite Winter Camp for Girls
Registration Form
Liberty University
“Building Champions for Christ!” Dates: February 26th — February 27th, 2011
Registration & Check-in: 8:00 a.m. on Saturday 26th at Thomas Indoor Soccer Center
This camp caters to the high school student who seeks to sharpen her skill level and has a strong desire to play at the collegiate level.
The camp is open to any and all entrants who are presently in the 9th, 10th, 11th, or 12th grade, and is limited only by age, gender and
number . The camp will give the student-athlete the opportunity to be coached and evaluated by the Liberty University soccer staff.
Camp ends: 12:00 pm on Sunday February 27th
Camper Benefits:







Devotions
Tactical Training
Technical Training
Small-sided games
Speed and Agility Evaluation by CSCCA certified Strength Coach
Liberty Soccer T-shirt
Qualified Athletic Trainer On Camp Staff
Cost:
Residential Camper — $125.00 (includes 1 night housing at a local hotel — double occupancy,
lunch and dinner on Saturday as well as breakfast on Sunday)
Commuter Camper — $75.00 (includes lunch and dinner on Saturday)
Attention: Women’s Soccer 1971 University Boulevard Lynchburg, VA 24502 Phone: 434‐582‐2389 Fax: 434‐582‐2205