EmailMe Form - Summer Camps Registration

Player Name *
First Last
Gender *
Male
Female
Date of Birth
(Player) *
MM / DD / YYYY
Camp Option Desired *
Full-Day and Half-Day options
Camps Available *

June 22 July 6 July 13 July 20 July 27 August 3

Camp Week
Camp Program *
Beginner - Intermediate - ages U6-U11
Intermediate - Advanced - ages U8-U13
Advanced - Ages U14-U18
Coaches will confirm player placement on first day of camp
2014-2015 Club Player?
2014-2015 Academy Attendee?
If your son/daughter was on a BUSC club team or attended an Academy session you will receive a $10 refund check.

Responses will be verified, blank responses will be treated as "No"
Club Name
If 2014-2015 club player please indicate Club
Team Name
If 2014-2015 club player please indicate Team
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Parent/Guardian Name *
Contact Email *
Cell Phone *
### - ### - ####
Other Phone
### - ### - ####
Emergency Contact Name *
Cell Phone *
### - ### - ####
Other Phone
### - ### - ####
Family Doctor
Doctor's Phone
### - ### - ####
Camp Shirt
T-Shirt Size *
Medical Conditions & Allergies
Signed Medical Release Document (PDF or JPEG)
Referred by *
Year
Image Verification

Please enter the text from the image:
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Total	$0.00

Belmont United & San Carlos Soccer Club is a 501c (3) compliant non-profit organization, Version 1/1/2012 P.O. Box 403, Belmont, CA 94002

	June 22	July 6	July 13	July 20	July 27	August 3
Camp Week