DS SportsPlex Summer Soccer Camp

Medical Release Form
Emergency Contact*
First Last
Phone*
Allergies*
Medical Conditions*
Physician's Name*
First Last
Physician's Phone*
Medical Insurance Providers*
Insurance Policy Holder's Name*
Policy Number*
Insurance Provider Phone Number*
Saint Andrew's School and Camp maintain privacy over your child's health information. In accordance with this policy, access to all health information is limited to the nurse, counselors and administrators and is only utilized for the safety and protection of your child or in an emergency.
The parents consent to medical treatment by the camp nurse as needed as well as transportation to the closest hospital in the event of an emergency by ambulance. All efforts will be made to contact the parents in the event of an emergency.
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Payment Form
Today’s Date
Date Format: MM slash DD slash YYYY
Camp June: Week 22 - 26*
Price: $150.00
Camp June: Week 29 - July 3*
Price: $150.00
Camp July: Week 6,7,9 & 10*
Price: $150.00
Camp July: Week 13 - 17*
Price: $150.00
Camp July: Week 20 - 24*
Price: $150.00
Camp July: Week 27 - 31*
Price: $150.00
Camp August: Week 3 - 7*
Price: $150.00
Camp August: Week 10 - 14*
Price: $150.00
Training Soccer Camp, Half Day $150 per Week
$0.00
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- Upon checking this box, you will be providing Colo Colo Soccer Academy USA with valid and updated credit card information. If you provide your credit card information to Us, You authorize Us to charge such credit card for all Purchased Services, including Registration Fees, or Ongoing Training Fees. Early termination from Training Fees requires a written notice to colocolosoccerusa@gmail.com 30 Days in Advance.

Medical Release Form