Kicking Academy Saturday, July 10, 2010 9:00 AM –12:00 Noon Growney Stadium St. John Fisher College 3690 East Avenue Rochester, New York !!!"#$%&’(())$*+"(,’ -./- .12 Kicking Academy Registration Form Name _______________________________________________ Date of Birth ___________________________ Age ________ Address _____________________________________________ City _______________________ State ______ Zip __________ Email _______________________________________________ School ______________________________________________ Grade in School _________________ Position _____________ Parent/Guardian Name _______________________________ Home Phone_________________________________________ Work Phone _________________________________________ Email _______________________________________________ Health Insurance Carrier ______________________________ Policy Number _______________________________________ No one will be allowed to participate in the KICK IT! Kicking Academy without valid Health Insurance information. We (I) hereby give permission for the above mentioned to participate in the 2010 KICK IT! Kicking Academy on Saturday, July 10, 2010. We (I) hereby waive and release Camp Good Days and Special Times, Inc.; St. John Fisher College; and all their volunteers and staff involved, of any liability or claim in association with anything that may occur while my child is participating in the KICK IT! Kicking Academy. We (I) hereby also grant permission for the above mentioned to participate in any audio-visual event that may take place in regards to KICK IT! Kicking Academy and release Camp Good Days and Special Times, Inc.; St. John Fisher College; and everyone involved of any liability or claims in association with media coverage, if such takes place. KICK IT! KICK IT! KICK IT! Participant Signature (18 or older) ___________________________________ Date ____________ Parent/Guardian Signature (if under 18) ___________________________________ Date ____________ Please return completed forms, with payment to: Camp Good Days & Special Times Attention: KICK IT! Kicking Academy 1332 Pittsford-Mendon Road, PO Box 665 Mendon, NY 14506 Fax to: 585-624-5799 Register online: www.campgooddays.org Payment Information: $100.00 per participant !"Check Enclosed (payable to Camp Good Days) !"Please Charge My: ___Visa ___MasterCard ___AMEX Credit Card Number ____________________________________ Exp. Date ______________________________________________ Cardholder Signature___________________________________