___ Boy ___ Girl ___

Field Player ___ Goalkeeper

Date of Birth _________________
Player's name __________________________________
Parent's name __________________________________
Day phone (____)_____________ Evening (____)_____________
Address _________________________________________
City ____________________ State ________ Zip __________
Emergency contact _______________________________ Emergency Phone (____)_____________

My child is in good health and has my permission to participate in camp activities. If I cannot be reached in case of an emergency, I hereby give my permission to the physician selected by the camp staff to secure proper treatment for the above named individual. I understand that all pictures or video taken at the camp may be used at the discretion of the Arizona Sahuaros.

Parent or guardian signature ___________________________________________ Date ________________

Payment:
_____ check enclosed-payable to "F.C.J.C."
_____ charge my credit card $ ____________
_____ Visa _____ Mastercard _____ Amex
credit card # ___________________ Exp. Date ______

Date of camp or camps attending:
_____ June 3-7 _____ June 10-14 _____ July 8-12 _____ August 5-9

Level: _____ Intermural _____ Club _____ Travel

T-shirt: _____ YM _____ YL _____ S _____ M _____ L _____ XL