Mira Costa Girls Summer Soccer Camp Application

Mira Costa High School Girls Summer Soccer Camp Application
Monday, July 9th to Friday, July 13th from 1:00 PM to 4:00 PM
Application

Enrollment information:
• You must fill out a separate registration form for each student.
• No application will be considered without payment and all information requested.

(Fields with * MUST be filled in!)

Student's Name*

School & Grade Level*

Date of Birth*

Parent's Name *

Best Parent E-Mail*

Home Phone*

Cell/Daytime Phone*

My child may walk/bike home after camp without Parental Supervision?

EMERGENCY MEDICAL CONSENT FORM

In the event I cannot be reached, permission is hereby given for the physician or hospital designated below to provide emergency care for my child should serious illness/injury occur during camp hours. I also authorize the Mira Costa High School Girls Soccer Camp Director or member of the Soccer Camp staff to offer consent to medical attention by calling 911 and/or to offer consent as needed.

Student's Name (For Consent Form)*
*
Parent or Guardian (Dr./Mr./Mrs./Ms.)*

Emergency Contact 1*: Daytime Phone: Cell/Page:
(you may enter "same as sibling name" if you have filled out a sibling form)

Emergency Contact 2*: Daytime Phone: Cell/Page:
(you may enter "same as sibling name" if you have filled out a sibling form)

Physician Name, Address, Phone*:
(you may enter "same as sibling name" if you have filled out a sibling form)

Health Insurance Name, Address, Phone*:
(you may enter "same as sibling name" if you have filled out a sibling form)

Is there any medication student MUST take during camp hours?

Are there current health problems or allergies to drugs or foods (specify)?

Any other information that program staff should be aware of in order to best care for your child:?

Mira Costa Girls Soccer Camp Code of Conduct:
A safe and positive learning and “fun” environment will be maintained at the Camp at all times. Students are expected to respect the personal rights of their peers and to abide by the expectations of instructors and all camp staff. In the event of misconduct, the parent will be notified. If the unacceptable behavior is repeated, the child will be removed from the remainder of the week’s activities without refund. Mira Costa Booster Club and the Manhattan Beach Athletic Foundation thank students and parents for respecting the Code of Conduct and for contributing to an enjoyable and enriching experience for all children.

PLEASE CAREFULLY REVIEW APPLICATION BEFORE SUBMITTING!
After submitting, the payment page will appear.
Note! You are NOT registered until payment is completed.

NAME OF PERSON FILLING OUT FORM*

E-MAIL OF PERSON FILLING OUT FORM*
Your online parent signature indicates acceptance of all guidelines and policies stated in these forms including reading and agreeing with the Code of Conduct above.

If you encounter problems filling out this form, e-mail us at kathy@wvcpas.com