REGION 15 MIDDLE SCHOOLS
GIRLS SOCCER CAMP
Registration Form
ONLY FOR GIRLS ENTERING 9th GRADE IN SEPTEMBER, 2011
Dates, Time & Place: August 22 through August 26; 4:30 pm to 8 pm, PHS Turf Field.
Coaching Staff: Tom Maupin, PHS Girls JV Coach & Varsity players as assistants.
Fee: $60. Payable to PHS Athletics
Registration: Complete this form and return to Athletic Office, MS Girls Soccer Camp, Pomperaug HS,
234 Judd Rd., Southbury, CT 06488.
Student Name: _______________________________________________
Home Phone # :________________ Emergency Phone #: ________________
Mothers work or cell #: ____________ Fathers work or cell #: ____________
Home Address: _________________________________________________
Email Address: _________________________________________________
List medical conditions that may affect your child’s safe participation and/or provide information that you
consider of importance in case of injury or care of your child in an emergency situation.
I agree to hold Region School District 15 and any person connected therewith, harmless from any and all claims
from bodily injury and property damage arising from the use of facilities or during the course of an activity
sponsored by the above organizations. I give my permission for my child, named above to participate and
understand that such activity involves the potential for injury, which is inherent in all sports. Injuries are
always a possibility. On rare occasions, these injuries can be so serious as to result in total disability, paralysis
or even death.
Parent/Guardian signature and date signed: ___________________________________