Camper First Name *

Camper Last Name *

Which Clinic? (Check all for which you wish to sign up) *
February 16, 2025, 1-3:30pm

Camper Email *

Date of Birth *

Address Line 1 *

Address Line 2

City *

State *
(Select a state) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Washington DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming International

Zip Code *

Camper Phone (ex. 555-555-5555)

Parent/Guardian Phone * (ex. 555-555-5555)

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Email *

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone * (ex. 555-555-5555)

School Attending (This Fall) *

High School Graduation Year *
(Select a year) 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034

Club Team

Years Played *
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Position *
(Select a position) Field Player Goalkeeper Beginner

Do you currently have or have you ever had any of the following (check all that apply)? *
Heart murmurs Epilepsy Diabetes Asthma Allergies Surgery Insect stings Inhalers Heat exhaustion Fractures Medications Sprains None of the above

If you answered YES to any of the above, please explain:
0

Have you ever sustained a head or spinal injury? Have you ever lost consciousness?
Yes No

If YES, please explain:
0

Insurance Information:
Policy Holder

Insurance Company

ID #:

I certify that the registered party has a current physical on file and has been cleared for rigorous activity, with any exceptions therein noted above.

I hereby acknowledge and understand that this activity is a privately run activity, and is not operated by or through Davidson College. The activity is not sponsored, controlled, or supervised by Davidson College, but rather is under the sole sponsorship and supervision of the Camp Director, Zoe Almquist.

I hereby acknowledge and understand the refund policy.

I understand and accept the agreement and liability waiver ("Agreement and Waiver").

By entering my name below, I assert that I have reviewed and agree to all the waivers and agreements I selected above.
Name (or Name of Parent/Guardian if Participant is a minor) *

Date *

(Note: If you are on a safari desktop browser and cannot get the date to work, try putting it in YYYY-MM-DD format, e.g. 2022-04-10)