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Registration Form

NJ Wildcats

To Register:

Mail this Registration Form and Payment to:

NJ Wildcats, 16 Doreen Drive, Oceanport, NJ 07757

                                                 or

Fax this Application with your Credit Card information to 732-298-7619

 Campers First Name  Campers Last Name
 Age  Date of Birth
 Sex  Street Address
Apt #  Town
 State  Zip

 Parents First Name  Parents Last Name
E-Mail Address  Home Telephone
Work Telephone  Emergency Contact
 Emergency Telephone Special Medical Information
Insurance Company Insurance Card Number
 Camp/Clinic Location  Camp/Clinic Code
Name of the program Season
 Camp/Clinic Time Camp/Clinic Fee
  Payment Type Credit Card Number
Signature Expiration Date

I hereby agree to allow my child to participate in the sport of soccer. I understand there are certain risks of injury inherent in the practice and play of this sport as well as traveling and other related activities incidental to my participation and I am willing to assume these risks. I herby certify that my child is fully capable of participating in the sport of soccer and he/she is healthy and has no physical or mental disabilities or infirmities that would restrict full participation in this activity. In addition, to giving my full consent for my child's participation, I do herby waive, release, and hold harmless NJ Wildcats, it's officers, coaches, sponsors, supervisors, and representatives for any injury that may be suffered by my child in the normal course of participation in the sport of soccer and the activities incidental thereto, whether the result of negligence or any other cause. I grant permission for my child to receive emergency medical treatment from trained emergency medical professionals. I understand that the staff will not perform any invasive procedures of any kind nor be responsible for the disbursement of medications. I grant NJ Wildcats permission to use photographic or video images in future promotional materials.

Legal Guardian Signature______________________________________ Date_______________