Select Camp: Select One Residential Camp Day Camp (Full) Day Camp (Half)                                                                               Week: Select One June 22 - 27, 2008 July 13 - 18, 2008

Parent/ Guardian Information:

Name:     E-Mail:

Address:

City:      State:      Zip:     Country:

Home Phone: Cell Phone: Work Phone: Fax Number:

Emergency Contact/ Medical Information:

Name:     Phone:

Family Doctor:     Phone:

Camper Allergies/ Known Conditions:

Last Tetanus:     Family Health Insurance Company: Policy Number:

Camper Information:

Name:     Age:     Gender:

Uniform Shorts Size: Select One YS YM YL AS AM AL AXL (Short size does not apply to day camps)    Uniform Shirt Size: Select One YS YM YL AS AM AL AXL

What name would you like on the back of the jersey?

I would like my roommate(s) to be* -

We will make every effort to fulfill roommate requests.  Please separate multiple names with a comma.

Payment Method:

Options: Select Payment Options Visa MasterCard Sending Check           Payment Amount: 
*Please make check payable to: Cocoa Expo Sports Center Inc. Soccer Camps

Credit Card Number:     Expiration Date:     Name on Card:

Your Application is not considered official until your Application Fee is received by Cocoa Expo,
I understand that the directors and coaches of University of Soccer or Cocoa Expo Inc., or anyone associated with Cocoa Expo Sports Center, Inc., will not assume responsibility for medical and dental expenses incurred as a result of participation in the program. The applicant is covered by our family accident and health/dental insurance, is in good health, and able to participate in the physical activity of a vigorous program. I hereby authorize the camp directors to act for me, according to their best judgment, in any emergency requiring medical attention. I will hold harmless the directors and coaches of University of Soccer and Cocoa Expo, Inc., or anyone associated with Florida Institute of Technology and the Cocoa Expo Sports Center of any and all liabilities, causes of actions, claims and demands of any kind and nature whatsoever that may arise in connection either with or resulting from participation in any activities. All campers or legal guardian must notify the University of Soccer camp staff in writing of any medical conditions that may affect the campers participation.
Please check that you have read the liability release