2006 Fall Soccer Camp

By

YMCA/Mountain State University Men’s Soccer Team

When:          September 11th -15th

Where:         YMCA/Paul Cline Sports Complex

Time:            5pm-7pm

Ages:            4-12

Cost:            $55

Mountain State University Men’s Soccer Team will be holding a fall soccer camp for local athletes.  The Men’s Soccer Team is competing in their first season.   Current players and coaches will provide each camper individual attention and support.

Sessions will be held to give each camper a better understanding of the skills needed to perform at their maximum ability. The camps will be designed to improve each campers individual skills focusing on dribbling, passing, trapping, heading, and shooting.  These are the basic building blocks upon which your child can become the best that he/she can be while playing soccer.

For further questions please call:

John Birkelbach 304-929-1403

      Mail Registration to:

Beckley/Raleigh County YMCA Soccer Camp

Beckley, WV 25801

Camper Name_________________________________ Age_________

Grade______     School________________________________________

Address___________________________________________________

Phone (day) ________________ (evening) ________________________

Parents Name_______________________________________________

Emergency Contact Name_____________________Phone___________

Please note below any of your child’s allergies or medical conditions that the camp staff should be aware of __________________________________________

__________________________________________________________

__________________________________________________________

Special medical needs (if any)__________________________________

__________________________________________________________

Medical Insurance Information

Insurance Company Name____________________      Policy#____________

Policy Holder’s Name_______________________      Exp. Date__________

Physician’s Name___________________________     Phone_____________

Hospital_____________________________________________________

Medical Waiver

I, parent or legal guardian of ______________________, gives my permission for him/her to participate in the 2006 Mountain State University/ YMCA 2nd Annual Age Groups Summer Soccer Camp.  I attest that he/she is physically capable of participating in this camp.  I understand that neither the Mountain State University/Beckley-Raleigh County YMCA nor the Camp Director or instructors have medical insurance and  I release them of any liability resulting from injuries sustained by my child during camp activities, I further authorize the camp staff to act on my behalf in any emergency situation involving my child.

Signature of parent/guardian___________________________________

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For office use only:

Membership #________________Expiration_______________Rec’d___________

Check #________________ Amount_____________