Please print this page using the 'File - Print' function of your web browser, fill it in and mail it enclosing a check or money order to: Nicolae Piperea - 19 Perna Lane - Stamford, CT 06903
Should you have any questions, please call (203) 595-9831 or (203) 613-1033 or (203) 622-0004
Athlete's Name:______________________________ Age:___ Birth Date: ________
Parent Name: __________________________ Cell Phone ____________________
Emergency contact:___________________ Phone: _________ Cell Phone________
Address:_________________________________________________
Street
__________________________________ ______ ____________
City State Zip
Phone: ____________________ E-mail: __________________________________
Circle the program/s and class/es that you would like to attend:
Summer Soccer session:
9:00-9:45am (3-4 yr. olds)
9:45-10:30am (4-5 yr. olds)
10:30- 11:30am (6-8, and 8-11 yr. olds)
$25 discount will be applied to those who are doing at least one week of Summer Camp. A special 10% discount for each sibling.
fee for the Saturday Summer session: $250
for 45 min. cls(3-5 yr. olds) and $270 for 60 min. cls.(6-11 yr.olds)
[ ] I have
enclosed a check or money order for (Please make checks
payable to Nicolae Piperea)
Saturday summer soccer session: [ ] $250 for 45 min. class(3-5 yr.olds) [ ] $275 for 60 min. classes(6-11 yr. olds)
[ ] Other amount (please specify) :_________________________________________
HEALTH CERTIFICATE : My daughter/son is in good health and has my full permission to participate in the Soccer Camp. She/He has no previous sickness, illness, or disease or bodily injury that is adverse to participation in the Soccer Camp. It is understood that the medical insurance policy insures against loss resulting directly from participation in the Soccer Camp not exceeding $2000 and after your own insurance has been used. The law requires that parental permission be obtained so that urgent medical attention can be administrated to minors. The following consent form should be signed by the parents in order that such procedures as be necessary may be conducted without due delay. However, no major operation will be performed, except in extreme emergency, without the parents contacted and fully informed.
I hereby give my permission for such diagnostic and therapeutic procedures as maybe deemed necessary for my child and also, to present information concerning his/her medical condition to our responsible camp officials when deemed desirable.
Signature:___________________________