(415) 460-9060
NORTHERN CALIFORNIA COERVER SCHOOL OF SOCCER
Please print and complete form.
Mail registration form and check (payable to Coerver-Norcal) to:
Camp or clinic date: ______________________________
Location of camp: ________________________________
Age of student: _____ If signing up with a team, please list team name______________
Note: cancellations made 14, or fewer, days before the camp will receive voucher for future camp
WHAT TO BRING: Soccer ball, water bottle, shin-guards, cleats, and a positive attitude!
LAST NAME______________________________FIRST NAME__________________
EMAIL ADDRESS__________________________AGE/YEAR OF BIRTH___________
MAILING ADDRESS___________________________PHONE (_____)____________
PARENT NAME(S)_________________________BUSINESS PHONE_____________
List any allergies or restrictions ________________________________________________
Doctor to notify in case of emergency _______________________PHONE_____________
Person to notify in case of emergency _______________________PHONE_____________
I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the rules of the COERVER COACHING SCHOOL, its affiliated organization and sponsors. Recognizing the possibility of physical injury associated with soccer, I hereby release, discharge and otherwise indemnify and hold harmless Coerver Coaching, Ron Benjamin, Jason Werner, including the owners of the fields utilized for the programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Coerver Coaching School.
As the parent or legal guardian of the above named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Dentistry. This care may be given under conditions, whatever conditions necessary to preserve life, limb, or well-being of my dependent.
PRINT NAME__________________________SIGNATURE____________________DATE__________
Legal parent/guardian Legal parent/guardian