Georgia International Soccer Academy, LLC

							                                          Georgia International Soccer Academy, LLC
                                 ADVANCES IN SOCCER SUMMER 2012 CAMP
                                                       June 18, 2012 to June 22, 2012
                                            Campbell High School Ward Street, Smyrna, GA 30082
                                                                        Please Print
Today’s date:
                                                           PERSONAL INFORMATION
Last name:                                            First:                                     Middle:
Primary Position:                                     School or Club ( if applicable)
Grade                                                 M           F        DOB:         /      /                  Age:
Street address:                                                                                Primary phone        (      )
City                                  State                Zip code                            Alt Phone            (       )
T-Shirt                               Shirt size ( circle one) YS               YM            YL        AS         AM           AL
PARENT INFORMATION                    Last name                                                First name
                                      Last name                                               First name
                                      E-mail                                                  Alt E-mail
How did you hear about the course (please check one box):
 Family             Friend         Club official                            On-Line        e-mail        Brochure               Other

Registration fee :
    Soccer FUNdamentals $75      M-F 5:30 to 8:00 p.m.
    Advances in soccer-club $130 M-F 5:30 to 9:00 p.m.
    Advances in Soccer HS $170 M-F 9-11:30 a.m. and 6:00-9:00 p.m.

Mail checks and completed form to 4480-H South Cobb Drive #306 Smyrna, GA 30080.
Teams should have coach or manager contact G-ISA for group payment.
                                          See full program details at ww.GA-ISA.org
Liability Release: I hereby assume all risk of accident, harm or injury to the child which may arise from participant in the G-ISA summer camp
program and therefore indemnify, defend, release and hold harmless forever and discharge the camp, Cobb County Schools, Garvin Quamina, Carla
Neal-Haley, contractors, agents and other personnel for liability, claims, demands, costs and actions that may result from participation in the camp. In
addition, I hereby give my permission and authorization for emergency or routine medical treatment in the event I can not be reached in a timely
manor. Furthermore, I understand that pictures obtained during camp sessions may be used for G-ISA marketing and advertising.

                                                           PAYMENT INFORMATION
Please make checks payable to GA-ISA
PayPal on-line at www.ga-isa.org                          Confirmation #
Official use only
Cash                     $                     Receipt:
Ck                       $                     Ck #
                                                            IN CASE OF EMERGENCY
Personal Physician                                                             Allergies :
Emergency Meds:                 Albuterol MDI               Epipen              Benadryl                 Other _____________
Medical Conditions :
Name of local friend or relative (not living at same address):             Relationship to patient:        Home phone no.:       Work phone no.:


Signature                                                                                                   Date

        Georgia International Soccer Academy, LLC          4480-H South Cobb Drive, #306 Smyrna, GA 30080                            (678)557-7524