SPONSORSTHANKS TO OUR

Please Print the following information

Child’s Name:_______________________

Circle One: Male / Female

Age:_________ Birthdate: ____/_____/_____

Home Number (_____) - _______-____________

Address: _____________________________________________

_____________________________________________

city state zip code

Parent email:______________________________

School That Child Attends:______________________________________

Emergency Contact Information:

Name:_____________________________

Contact Number: (_____) - _______-____________

Special Needs/Allergies (Asthma, Medication,etc.):_______________________________

MANDATORY SIGNATURE OF ACCIDENT RELEASE FORM ON BACK.

LEGION FIELD1301 W GREGORY ST.PENSACOLA FL 32502

TUESDAY, AUGUST 6 - THURSDAY, AUGUST 8

KickStart ApplicationFill out this form, cut it, and return to the Pensacola Sports Association (PSA), drop by, email, or mail toPensacola Sports Association101 West Main StreetPensacola, FL 32502(Deadline for Pre-registration is Thursday, August 1, 2013 and Prizes are on a first come first serve basis) (Registration will be available on an online form as well as on the day of the event, but pre-registration is MUCH preferred)

Circle Incoming Grade Level:5th & 4th Grade

3rd & 2nd Grade

1st Grade Mission Statement: To kickstart an interest in soccer in kids who have never been exposed to the sport or have not had a chance to gain formal instruction, all while providing a new, healthy, and safe outlet for free time during the summer.

FREE SOCCER CAMP

Pensacola KickStartSummer Soccer Program

2nd Annual

2013 KickStart Soccer ProgramSchedule:Tuesday, August 6, 2013 - Thursday, August 8, 2013

9:00 - 9:15 AM Check-In

9:15 - 11:30 AM Activities

Details:• Age Divisions (1st), (2nd & 3rd), & (4th &

5th)

• Unlimited Enrollment- Please Register Prior so Necessary Preparations can be Made.

• Bring Water and/or Gatorade to make sure to stay hydrated.

• Register by Thursday, August 1, 2013 or on the day of the event.

• (Registration will be available online and on the day of the event, but early registration is much preferred)

PRIZES!!Kids who complete registration by Wednesday, August 1, 2013 will be put first. Prizes are on a first come first serve basis.Also Kids who perform well during the camp will receive prizes at the end for their efforts. Some of these awards include Hard Working, Good Sportsmanship, Skill, and Most Improved.

General Information:• Participants are required to bring cleats or

tennis shoes to play (NO OPEN TOED SHOES)

• Participants are encouraged to put on sunscreen before coming to camp

• REGISTER by Thursday, August 1, 2013 or on the day of the event.

• (Registration will be available on the day of the event, but early registration is preferred)

• Located at Legion Field,1301 W Gregory St, Pensacola, FL 32502

For any Questions and/or Concerns please call the PSA at (850)-434-2800

I, releasor, being of lawful age as the participant or being the parent or legal guardian of the participant, in consideration of

____________________________

(name of participant)

being permitted to participate in the KickStart Summer Soccer Program, hereinafter called :”the event”, hereby for myself and for my child or ward if the participant is a minor of for our spouses, heirs, legal representatives, and assigns, hereby release, waive, discharge, and agree to indemnify and hold harmless the Pensacola Sports Association its officers and members, and all promoters, organizers, sponsors, and advertisers of the event, and all owners and leasees of any premises where the event is conducted, and each of them, their officers and employees, hereinafter “releasees” from all liability of and from any and every claim, demand, action, or right of action, of whatever kind or nature, either in law or in equity arising from or by reason of any bodily injury or personal injuries known or unknown, death or property damage resulting or to result from any accident which may occur as a result of participation in the event or any activities in connection with the event, whether by negligence or not except in the extent and in the amount covered by accident or liability insurance. Releasor understands that participation in sporting activities is inherently dangerous and hereby assumes all risks and hazards incidental to participating in the event. Releasor expressly agrees that this release is intended to be as broad and inclusive as permitted by the laws of the State of Florida. Releasor further states that he has carefully read the foregoing release and knows the contents thereof.

___________________________________________

Parent/Guardian Signature Date

CUT HER

E

Release