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2010 Larchmont Application Form
Name____________________________________________
Address__________________________________________
City_____________________State______Zip____________
Date of Birth________________________ Age ___________
Parents Name______________________________________
Home Phone( ______ )______________________
Work Phone ( ______ )______________________
EMail___________________________________
Emergency Contact
Name_______________________Phone________________
Physician____________________Phone________________
| My child
has been checked by a physician and has my
permission to participate in this camp. In the event
of an emergency requiring medical attention,I hereby
grant permission to a physician or hospital
designated by the camp to attend to my child. I
understand and accept that the practice of soccer
involves certain risks of physical injury. I
release, discharge, and hold harmless Kinderkickers
LLC, their organizers, employees, and supervisors
from any and all claims, actions, damages, losses,
liabilities, costs and expenses of any kind
whatsoever, including but not limited to any claims
arising out of or in connection with my child’s
participation in any Kinderkickers LLC program or
activity. Photo Permission - I permit the taking of
photographs of my child during recreational
activities for publication and use by Kinderkickers
LLC for promotional purposes unless otherwise
stated. |
Please list any special conditions ie allergies that
may exist.
________________________________________________
(Signature of parent or guardian)
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Date and Camp: |
[
]August 16-20 |
[ ]August 23-27 |
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[
] All Day Camp($325)
[
] Team Camp($325) |
[
] Half Day Camp($210)
[
] Kinderkickers ($210) |
Make checks payable to:
The Town of Mamaroneck Recreation Department
Mail to:
Soccer Camp
Town of Mamaroneck
Department of Recreation
740 West Boston Post Road
Mamaroneck, NY 10543
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