Week 1: June 24th -June 29th Week 2: July 1st – July 6th Boys and girls age 8-17 $125 per week includes T-shirt

Name:____________________________________Age:________________________________

 

D.O.B:___________________________________ PO box:_____________________________

 

Home Tel #:_____________________________Work Tel #:__________________________

 

Cell: T-shirt size:________________________# of weeks:___________________________

 

Please enclose Payment – all checks to be payable to FC Nassau

 For info contact

 Coachtony@fcnassau.com or Tel: 557 4374

 By Signing this form I agree that I have made arrangements through insurance for payment of medical bill which may be incurred if my child sustain an injury while participating in the FC Nassau Summer Camp, I waive all claims against FC Nassau and its staff for reimbursement of medical bills and damages sustained on account of any injury which may occur to my child.

PARENT/GUARDIAN Name:_____________________________________________________ Signature:____________________________________________________________________