www.havelocksoccer.com The HYSA camp program, which comprises individual and small group skills, incorporates individual skill development and healthy competition in a fun environment. Campers experience game related activities as well as age appropriate small sided games. This camp program is open to players aged 7 to 14. No lunch required but campers should bring a water bottle and may bring a snack. June 20th to June 24th from 7:30 am to 12:00 pm Registration fee $65 (Register by May 1st and pay only $55) ENCLOSE BOTTOM HALF AND FEE PAYABLE TO “HYSA” Please mail to: HYSA - PO Box 671 - Havelock, NC 28532 Net Blasters Soccer Academy Application (Complete one application per child) Camper Name:__________________________________ Age:_____________ DOB:_______________ Sex: Circle M / F Home Address:_______________________________________________________________________________________ Email Address:_______________________________________________________________________________________ Medical Insurance and ID#:_____________________________________________________________________________ Home Telephone:_____________________________________________________________________________________ Emergency Contact (Academy Hours):___________________________________________________________________ Allergies:___________________________________________________________________________________________ T-Shirt Size (YS, YM, YL, AS, AM, AL, AXL):____________________________________________________________ I, the below signed, as official parent/guardian of the above camper, certify my child to be in good health and give my permission for their participation in this club sponsored “Summer Soccer Academy.” I authorize all emergency and medical treatment which may be needed in the event of injury. I also understand that insurance coverage is my own responsibility. I understand the camp fee is non-refundable once the camp begins. I further understand there is a minimum $25.00 fee for returned checks. I hereby remise, release, and forever discharge the HYSA and all others listed hereafter: organizers, sponsors, officers, board members, commissioners, coaches, and landowners. I have no objection to the use of camp photographs in promotional material. Parent/Guardian (Print) ______________________________ Parent/Guardian (Sign) ______________________________ Office Use Only Check Number __________ Date Received __________ Amount $___________