All participants must send immunization records and clearance
from a doctor to participate in camp.
This is a state of Massachusetts requirement.
Camper’s Name _________________________________________
Birthdate ____________ Age___________ Male Female
T-shirt size: Youth S M Adult S M L XL
City, State, Zip___________________________________________
Work/Emergency Phone_ _________________________________
Does the camper have, or has he/she had, any problems with any
of the following?
allergies bee stings heart condition
upset stomach asthma diabetes
rheumatic fever other __________________
Is the camper taking medication? Y N
Are there any activity restrictions the staff should beaware of? Y N
(If yes, attach explanation on separate sheet.)
Medical Insurance Company and Policy Number
As parent/guardian of the above player, I certify that he/she is in excellent health and has no physical, mental or emotional problems which are likely to prevent participation in strenuous physical play at the Essex County United Soccer Camp. I agree to hold harmless Essex County United Soccer Club, and its agents, employees, counselors, volunteers, and coaches and hereby release them from any liability on account of injuries sustained by player while participating in soccer camp activities. I give permission for player to be medically treated for illness occurring or injury sustained during such participation and certify that he/she is covered by medical insurance which will reimburse Essex County United Soccer Club for expenses incurred by them, their agents, employees, coaches, counselors, and volunteers on account of medical treatment ordered at their discretion and also to indemnity them for any expenses not reimbursed by such insurance. I have read the above.
Signature of Parent or Guardian
______________________________________ Date __________
Send this form along with your $50 deposit for each camper to:
Essex County United Soccer Camps
179 County Road
Ipswich, MA 01938