2019 High Power Soccer Camp (Initial Child)
2019 High Power Soccer Camp (Initial Child)
Parent/Guardian First Name  * 
Parent/Guardian Last Name  * 
Street Address  * 
Apartment/Unit #
City  * 
Zip Code  * 
Parent/Guardian Home/Primary Phone  * 
Parent/Guardian Secondary/Cell#  * 
Child’s First Name  * 
Child’s Last Name  * 
Shirt Size (based on availability)  * 
Emergency Contact Name (other than parent/guardian already listed)  * 
Emergency Contact Phone Number  * 
Emergency Contact Relationship to Child  * 
Allergies and/or other medical issues
Your Email Address  * 
By submission of this form, I do hereby grant my child permission to participate in High Power Soccer with Paper Mill Road Baptist Church. I do hereby forever release and discharge Paper Mill Road Baptist Church, Inc., its representatives, staff and church members from and against any and all liability of whatever nature of kind resulting from an injury and/or death. I also grant permission for any representative, staff or church member to provide reasonable and necessary care to my child in the event of an injury or illness while on the church’s premises. I agree to accept financial liabilities from such care. I hereby give my permission for photographs of my child to be used for church purposes.
Total $
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