Dates	Your Preference
Saturdays - Stone Ridge School
Saturdays Jan 7 – Mar 3 11:00 – 12:30 for 6 – 8 year olds
Saturdays Jan 7 – Mar 3 12:30 – 2:00 for 9 – 12 year olds
Sundays - St. Albans School
Sundays January 8 - February 26 1:00 – 2:30 for 5 – 6 year olds
Sundays January 8 - February 26 2:30 – 4:00 for 7, 8 & 9 years olds (session full)
Sundays January 8 - February 26 4:00 – 5:30 for 10 – 12 year olds (session full)
	All camps $255 each

Camper’s Name

Camper’s Date of Birth

Gender: Male Female

Camper’s School

Choose size of tee shirt:

Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Adult Extra Large

GIYS Camps Previously Attended (if none, please write NONE)

Camper’s Allergies/Conditions

Parents and/or Guardians First and Last Name

Home Address

E-mail address

Home Phone Number

Cell Phone Number

Emergency Contact Name (other than parents)

Contact’s Relationship

Contact’s Phone Number

Child's Physician

Physician’s Phone Number

Health Insurance Carrier

Insurance Policy/Group Number

The parent or guardian of the camper must read, understand, and agree to the following statements:

In consideration of permission granted my child by Georgetown International Youth Soccer to participate in its program, I hereby give my permission for my child to participate in the program and activities run by Georgetown International Youth Soccer. I hereby release and discharge Georgetown International Youth Soccer, its agents, employees and officers from all claims, demands, actions, judgments, and executions which the undersigned's heirs, executors, administrators or assigns may have or claim against Georgetown International Youth Soccer, its successors or assigns, for all personal injuries known or unknown, and injuries to property, real or personal, caused by or arising out of the aforementioned sports activities, or any other activities run by Georgetown International Youth Soccer, which are incidental or necessary thereto. I further authorize Georgetown International Youth Soccer, its agents, employees and officers to arrange for any emergency medical care or treatment for my child which may be required as a result of participating in the aforementioned activities, and agree to hold Georgetown International Youth Soccer, free and harmless for any claims, demands, or suits for damages for any injury or complications whatever which may result from such treatment. I also grant Georgetown International Youth Soccer permission to use all pictures and video that might be taken of my child, during events, trips, and activities organized by Georgetown International Youth Soccer, for the purpose of promoting Georgetown International Youth Soccer. I have read this release and understand all its terms. I execute it voluntarily and with full knowledge of its significance.

The parent or guardian must enter their name and the date below to indicate their agreement with the preceding statements:

Name of Parent Guardian

Date

Be sure to submit your payment as soon as possible. Included in all fees is a non-refundable $50.00 application fee. Your cancelled check will be your confirmation of registration.

Paying by Check:
Please send $255.00 check payable to GYA, Inc. and send application and check to:

7904 Woodrow Place
Cabin John, MD 20818

Check #

Amount

Print this completed application, and send it along with your payment to:
Georgetown International Soccer
7904 Woodrow Place
Cabin John, MD 20818

How did you hear about us? (required)