Mifflin County Soccer Club Youth Soccer Camp Registration

Monday, July 21st through Thursday, July 24th
5:30 PM to 7:30 PM

Camp Director: Gregg Kanagy head boy's soccer coach for Lewistown High School
Location: Camp will be held at Lewistown High School soccer field
Registration Details
Mail registration and make check payable to:
Mifflin County Soccer Club
PO Box 663
Lewistown, PA 17044

Players Name: Male Female
Street Address:
Address (Cont.):
City: Zip: Phone:
Birth Date:
Grade Entering: Years Played:
Shirt Size: Small Medium Large X-Large
Parent/Guardian Name: Email Address:
Special Requests/Needs:

The undersigned agrees to defend, indemnify, and hold harmless the Mifflin County Soccer Club and it's officers, employees, and agents from and against any and all loss, liability charges and expenses (including attorney's fees) and costs whatsoever character which may arise by reason of participation in any program. (The Mifflin County Soccer CLub does not provide acciident, medical, liability, workers compensation insurance for program participants). As parent/guardian, I hereby consent to emergency treatment of my minor child as a result of accident or injury. I further agree to pay any and all costs incurred as a result of the said treatment. I agree to reasonably inspect and satisfy for myself that the facilities are safe for their intended use. Once having conducted the inspection, I agree to expressly assume the risk of participating at the premises.I understand the Camp retains the rights to use photographs or videos of campers taken at camp, for publicity or advertising purposes.

Parent / Legal Guardian Signature Block

(Printing your name signifies your signature)