Premier AC Day Camp Registration Form
                        All players MUST complete this form before participating in Premier AC activities.
                               Please note: Camp Slots are filled on a first come first serve basis.
                                           Cost: Under 8 - $175.00; U10 & up $200.00
       Player Name:  _______________________________                Sex (M/F):  _______________
       Birth Date:  _________________________________               Age:  ____________________
       Your Current Team______________________                      
          ************************************Parent/Guardian Information *************************************
       Name:  ____________________________________                  Relation:  _________________
       Address:  __________________________________                 County/City of Residence__________
                   __________________________________               Home #: __________________
       Email:  ____________________________________                 Cell #: ____________________
       *****************************************Other Information********************************************
       Emergency Contact:  _________________________                Phone #:  __________________
       Doctor’s Name:  _____________________________                Phone #:  __________________
       Allergies or Other Medical Concerns:  _____________________________________________
       Insurance Information:  _________________________________________________________
       *************************************************************************************************************
       Consent for Medical Treatment (Minor):
       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 Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the 
       life, limb or well-being of my dependent.
       X  ___________________________________________________       Date:  _________________________
           Signature of Parent/Guardian
       ***********************************************************************************************************
       Release Form:
       I, the parent/guardian of the minor Player, acknowledge that soccer is an inherently dangerous sport in which the Player participates at 
       his/her own risk. I, for myself and the Player and our respective heirs, administrators and successors, intending to be legally bound, 
       hereby release (1) Premier AC, its affiliated organizations and its sponsors, (2) its officers, directors, coaches, team managers, 
       volunteers, agents, representatives and assigns (collectively “Released Parties”), from and against all claims, liabilities, damages or 
       causes of action arising out of or in connection with the Player’s participation in any and all Premier AC programs. I affirm that the 
       Player is in good physical condition. I understand that Premier AC does not carry medical insurance for Players participating in tryouts, 
       practices, friendly scrimmages and other PAC sponsored activities, and that I am responsible for the Player’s insurance coverage until 
       the Player’s officially registered as a Player with the United States Youth Soccer Association.
       X  _________________________________________________         Date:  __________________________
           Signature of Parent/Guardian
       Please make checks payable to : Premier Athletics Club and mail to:  Premier Athletics Club  Attn: Camp 
       Coordinator 4201 Wilson Blvd # 110553 Arlington, VA 22203
                                           FOR ADMINISTRATIVE USE ONLY
                                              FOR ADMINISTRATIVE USE ONLY    PROGRAM _____________________     SEASON___________________
             PROGRAM ____________________________________________  SEASON ____________________________