Parental Consent Form

Please Print and Sign

Registration will be accepted until the camp start date if openings exist. Early mail-in registration is strongly recommended by deadline date of June 20, 2012  Make all checks payable to LGGSA and mail with completed forms to:                          

LGGSA
18 MarjorieWay
Hamilton, NJ 08690 

(Fully completed form must be submitted before camp participation)

Name _________________________________________________________

Birth Date _____________________________ Parent’s Day Time Phone Numbers: 
     Name_________________________________________ Phone_______________________

   Name_________________________________________ Phone_______________________

Emergency Contact Name__________________________________________  Phone_______________________

Physician's Name_________________________________________________  Phone_______________________

Known Allergies_______________________________________________________________ Current Medication______________________________________

Primary Health Insurance_______________________________________________________ Policy Number____________________________ Policy Holder____________________________ Secondary Health Insurance_____________________Policy Number___________________________

Policy Holder____________________________

Parent’s Authorization:  I hereby certify that the above listed information is true.  I understand that soccer is a physical sport.  I represent that I have consulted with my child’s doctor and he/she concurs that my child is physically fit and mentally capable of participating in soccer and camp related activity.  I hereby give permission for the camp staff to seek, during the times of camp, proper care for my child resulting from accidents, illness or injury.  I will be responsible for the cost of any and all treatment except for that provided by the camp’s excess medical coverage policy.  I, the undersigned, for myself, my heirs, executors and administrators, waive, release and forever discharge the camp, its entire staff and Mercer County Park, from all rights and claims for damages, injury or loss to personal property which may occur during camp, whether or not damages, injury or loss is due to negligence. I understand any photos used during the camp may be published to the www.lisagmittersocceracademy.com website or brochures and marketing material used for future camps.

 _________________________________           ___________________________

  Parent/Guardian Signature                                 Date