Soccer Clinics

Student Info

Student Name*

First Name

Last Name

Student's Age*

Student's Medical Conditions/Allergies*

Type "none" if your student doesn't have any conditions or allergies we should know about.

Program Registration

Which Spring Soccer Clinics do you want your child to attend? Check all that apply. Each clinic is $10. Register for all 3 at a cost of $30 and get a certificate for $10 off of summer camp registration to be used Summer 2019.

Soccer Clinic Dates

Sunday, March 10 Sunday, March 24 Sunday, April 7

Parent/Guardian Info

Parent/Guardian Name*

First Name

Last Name

Email*

Parent Number*

Secondary Phone

Emergency Contact*

Emergency Contact Phone*

Parent/Guardian Permissions Release

Permission for Medical Treatment, Release of Medical Information
and Payment of Medical Expense

I REQUEST AND GIVE PERMISSION to the physicians and medical staffs at locations near SUNY Cobleskill to treat the above-named participant appropriately, including hospitalization, prescribing medication and performing emergency medical procedures.

I AUTHORIZE release of any medical information which may be pertinent to any diagnosis or treatment of the above-named participant.

I UNDERSTAND that any charges resulting from this medical treatment will be billed to me at my address or tomy medical insurance carrier which is listed above.

Photo Release Permission

I hereby grant permission for SUNY Cobleskill to distribute or publish photographs and images made of me /mychild on campus and/or during college-associated events for the purpose of publicity, exhibition and ormarketing.

Your digital signature below affirms the boxes you checked above for medical and photo permissions.

Parent/Guardian Signature

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Use your mouse or finger to draw your signature above

Payment Information

Total* $

Name on the Card*

First Name

Last Name

Credit Card*

Billing Address*

Address Line 1

Address Line 2

City

State

ZIP Code