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2010 AYSA SUMMER SOCCER CAMP REGISTRATION FORM
PLAYER NAME: ________________________________AGE: ___________
ADDRESS: __________________________________________________________________
HOME PHONE: ______________________________________________________________
EMERGENCY PHONE: ________________________________________________________
E-MAIL ADDRESS (legible please):_______________________________________________
MEDICAL CONDITIONS: ______________________________________________________
Please check all that apply:
WEEK #1: June 28 - July 2 Age 5 thru 7 Half Day $125: _____ Age 8 thru 12 Half Day $125: _____ Age 8 thru 12 Full Day $200: _____
WEEK #2: July 26 – July 30 Age 5 thru 7 Half Day $125: _____ Age 8 thru 12 Half Day $125: _____ Age 8 thru 12 Full Day $200: _____
REFUND POLICY: Full refund for withdrawing for week #1: Prior to June 1, 2010 Full refund for withdrawing for week #2: Prior to July 1, 2010
Refunds will not be granted AFTER June 1 (for week #1) and July 1 (for week #2).
Location: Crocker Farm School Fields, Route 116, Amherst, MA
ALL CHECKS MADE PAYABLE TO “AYSA” PLEASE MAIL SIGNED, COMPLETED FORM AND CHECK TO: CHRISTOPHER STREETER: 524 Fuller Street, Ludlow, MA 01056
I understand and accept the condition that Christopher Streeter, AYSA, or any of the staff will not assume any responsibility for accidents or medical or dental expenses incurred as a result of participation in this program and that parents/guardians are responsible for providing medical/dental insurance for their children. The applicant is in good health and able to participate in the physical activities of this program.
Parent/Guardian Signature: ___________________________________________________________
Have a question?: christopherstreeter@yahoo.com or 413-244-6988www.amherstsoccer.org
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