Butler Soccer Camp Registration

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THERE ARE CURRENTLY NO ACTIVE CAMPS TO REGISTER FOR

Email address *

Player's Name *

Please Choose Camp Registering For: *

Primary Position *

Were you referred to our camp by your club/high school coach? If so, please enter his/her name below.

Birth Year *

T-Shirt Size *

Address *

City *

State *

Zip Code *

Name of School Attending *

Current Grade in School (just completed) *

Age *

Parent/Guardian Name *

Parent/Guardian Cell Phone *

Parent/Guardian E-Mail *

Medical Waiver Release and Medical Authorization: must be signed by a parent or guardian in order for player to participate in camp.

Release of Liability

In consideration of the Butler Soccer Camps granting the student permission to participate in the Butler Soccer Camps, I hereby assume all risks of his/her personal injury that may result from the Butler Soccer Camp activity. As parent/guardian, I do hereby release the Kansas State Board of Regents, Butler Soccer Camps and their officers, employees, all agents, all instructors, and all participants in said Butler Soccer Camps program from all liability, including claims and suits at law or inequity, for injury which may result from the student taking part in Butler Soccer Camps activities.

Health Statement/Medical Authorization

I do hereby affirm that the applicant is in good health and suffers from no illness, disability or condition that requires the taking of medication on a regular basis unless that condition is disclosed and approved. Furthermore, I have no knowledge of any reason that the applicant cannot participate in vigorous activity. I hereby authorize and give my consent to the health authorities of Butler Soccer Camps or any licensed physician or athletic trainer to perform upon or administer, without prior consent, any reasonable, necessary medical treatment my student.

I agree to assume all costs related to such treatment. I understand that I will be responsible for any medical or other charges in connection with student's attendance at this camp.

Please check the box below to accept our Medical Release and Waiver *

I have read and accept the medical release and waiver.

Parent/Guardian Signature (please enter initials and today's date) *

Insurance Company *

Policy Number *

After clicking submit you will be taken to the payment submission form.

Your registration WILL NOT be complete without submitting payment.

Thanks for choosing Butler Soccer Camps and GO GRIZZLIES!

There will be a $5.00 convenience fee to submit this online form.

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