2010 Chittenden County Soccer School

APPLICATION

Price

$85.00 until June 15th.
$95.00 after June 15th until July 7.
Final registration deadline is July 7.
- No exceptions. -

Dates

July 19-23, 2010

Location

Brown's River Middle School (Jericho, Vermont)

Participant's Name	:	________________________________
Age	:	______
Sex (circle)	:	M F
Grade entering in fall of 2010: Pre-K K 1 2 3 4 5 6 7 8 9 (circle) (groups will be determined by grade)
Height	:	______
Weight	:	______
Circle predicted shirt size (this July)
Youth small (6-8) medium (10-12) large (14-16)
Adult small(34-36) medium (38-40) large (42-44)
PLEASE SEND COMPLETED APPLICATION AND FEE TO:

Chittenden County Soccer School P.O. Box 214 Underhill,
Vermont 05489-0214

Each participant must be covered by his or her own family insurance policy.
Carrier	:	________________________________
Policy number	:	______
It is understood that the Chittenden County Soccer School does not provide medical insurance covering injuries of any nature. The undersigned hereby releases the Chittenden County Soccer School, its successors, assigns, officers, agents, and employees from any and all claims, demands and causes of actions whatsoever in any way growing out of, or resulting from, participation in the Chittenden County Soccer School.
Name of Participant (Please Print)	:	____________________________
Signature of Parent or Guardian	:	____________________________
Address	:	____________________________
Town	:	____________________________
State	:	____________________________
Zip	:	_____________
Phone (home)#	:	____________________________
Phone (work)#	:	____________________________
Date	:	_____________

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