Silverbacks Summer Camp Application

Cost is $75.00 per player 

State: __________ Zip: _________ 

Home Phone: ____________________

Cell Phone: _____________________ 

Emergency Contact: _______________

Emergency Phone: ________________

E-mail Address: __________________

Insurance: _______________________

Policy Holder: _____________________

Policy Number: _____________________

WAIVER AND RELEASE OF LIABILITY: In the case of medical emergency I hereby give my permission to Pike County Youth Soccer, Atlanta Professional Soccer LLC an/or its agents to secure medical treatment for my child. The person enrolling in the camp, his/her parent or parents, or legal guardian assumes all risk of loss of property or injury to that person. This includes all injuries and/or death caused by incidental dangers associated with soccer activities. I/we agree that there are certain inherent dangers related to soccer participation and therefore agree to hold Pike County Youth Soccer Association, Pike County Recreation Department, Pike County, Atlanta Silverbacks and related entities and individuals harmless, and specifically agree not to make claim against Pike County Youth Soccer Association, Pike County Recreation Department, Pike County and/or the Atlanta Silverbacks and all affiliated entities. The undersigned hereby certified that I(we) am(are) the parents or legal guardian of the camper.

Signed: ____________________ Date: ____________________

PCYSA  Board Members