Camper Name:

Circle:    Male    or    Female

Street Address: 

City, St, Zip:

Home Phone:

School next year            

Grade next year

Birth Date:

Current Team: 

Emergency Contact & Day Phone: 

Medical Insurance Co:

Policy #:

Family Physician:

Physician Phone:

        Recognizing the possibility of physical injury associated with the sport of soccer, I hereby release, discharge, and/or otherwise indemnify Matthew Paradise, its ownership, staff, affiliates and associated personnel, including the owners of facilities utilized by the camp against any claim made by or on behalf of the camper listed above as a result of the camper’s participation in camp activities.  I certify that the player above is in sound physical condition and capable of participating in soccer activities and that there are no medical conditions that would prevent his/her participation or be affected or influenced by the above named player’s participation in soccer activities conducted by Matthew Paradise.  In case of emergency, I authorize treatment to be given by my family physician or the nearest Hospital’s emergency department.  I permit Matthew Paradise and staff to act on my behalf in accordance with their best judgment in any emergency requiring medical attention.