Commonwealth Soccer Academy

Summer Camp

Camp Registration Form

The following registration information is required by CSC.

After completing this form, please send payment of $80.00 to 4229 Watertrace Dr., Lex, KY 40515

Last Name		First Name		Middle Name
Gender (M/F)		Date of Birth
Street		City		State
Zip
Parent or Guardian Name (First, Last, MI)
Home Phone		Cell Phone
Current School		Fall Grade
Email Address 1		Email Address 2		Email Address 3

Medical Waiver - Please read and accept or decline by entering "Yes" or "No" in the space provided below.
I authorize the representatives and staff of Pete's Soccer Skills Camp to act according to their best judgment in case of any emergency. I will not hold Pete Akatsa or any representative or staff member responsible for any unforeseen injury or illness.
Agree to Medical Waiver (Enter Yes or No)				Players Last 4 SSN