Please indicate the following information below.
No camp application is complete without this information!
Company:
Policy #:
Doctor:
Phone #:
In case of an emergency, it is necessary for us to have both home and work telephone numbers for the camper’s parent/guardian.
Home #:
Work #:
Camper’s Name:
I (please print)
Parent/guardian of above camper hereby authorizes the staff of Huskies Soccer Academy to act for me according to their best judgement in any emergency requiring medical attention for the above camper. I hereby waive and release Northeastern University, its corporators, trustees, employees, students, and agents from any and all costs, liability and expense for any personal injuries or illness in any way related to participation in the clinic program. I have no knowledge of any physical impairment that would be affected by the above camper’s participation in the camp program, as outlined in this brochure. I also understand the Academy retains the right to use, for publicity and advertising purposes, photographs of campers participating in the camp program.
Date: