Name of Camper ________________________________________________________________
Date of Birth ____________________________________________________________________
Please provide the following information about the above minor:
Allergic Reactions ________________________________________________________________
Present Medications ______________________________________________________________
Past illness or other information that would be useful in the event of treatment if necessary:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
In case of an emergency:
Father ___________________________________________________________________________
Mother __________________________________________________________________________
Home Phone ___________________________

Work Phone ____________________________
Cell Phone _____________________________ Beeper # _______________________________
Insurance company:
_________________________________________________________________________________
Policy holder:
_________________________________________________________________________________
Policy number:
_________________________________________________________________________________

I hereby authorize the Mark Mettrick Advanced Soccer School and the Mark Mettrick Professional Soccer Camp to act on my behalf according to their best judgment in any medical emergency. I verify to the best of my knowledge that the above named applicant is physically able to participate in the activities of the camp.

I the undersigned waive and forever discharge the Mark Mettrick Professional Soccer Camp's and the Mark Mettrick Advanced Soccer School at Loyola College and St. James School, its staff, officer, agents, representatives, employees and successors from and all rights and claims for damages to person or property while at the camp site. To register the camper must have valid medical insurance applicable during the selected soccer session.

I declare that I am the father / mother / guardian (circle one) of the above-named minor.
Signature _______________________________________________________________________
Date ___________________________________________________________________________
This form must be completed prior to registration, to allow camp participation.
Camp INFO - (410) 321 - 5025