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Mother Lode Church Soccer Camp
For players age 5- 13 is coming soon!
Sign up NOW! Reserve your spot!
When: Monday, 7/11 through Friday, 7/15
Soccer training begins promptly at 9 am
Ages 5-8 recommended: 9:00 - 11:30 am
Ages 9-13 recommended: 9:30 - 11:45 am
Where: Lotus Park Baseball Fields
Cost: $40 in advance or $45 at the park
BRING YOUR BALL, SHIN
GUARDS AND JOIN THE FUN!
Program Director: Stephen Beck
With a training staff of experienced
Competitive Players Age appropriate activities and fun games designed for
skill development, physical conditioning, and the
positive introduction to the fundamentals of soccer.
For more information contact:
Mother Lode Church
870 Beach Ct., Lotus CA 95651
(530) 622-0686
www.motherlodechurch.com
email: [email protected]
BRING YOUR BALL, SHIN
GUARDS AND JOIN THE FUN!
Program Director: Stephen Beck
With a training staff of experienced
Competitive Players Age appropriate activities and fun games designed for
skill development, physical conditioning, and the
positive introduction to the fundamentals of soccer.
For more information contact:
Mother Lode Church
870 Beach Ct., Lotus CA 95651
(530) 622-0686
www.motherlodechurch.com
email: [email protected]
Mother Lode Church Soccer Camp
For players age 5- 13 is coming soon!
Sign up NOW! Reserve your spot!
When: Monday, 7/11 through Friday, 7/15
Soccer training begins promptly at 9 am
Ages 5-8 recommended: 9:00 - 11:30 am
Ages 9-13 recommended: 9:30 - 11:45 am
Where: Lotus Park Baseball Fields
Cost: $40 in advance or $45 at the park
2014 MLC Soccer Camp Registration Name: Last First Date:
First Time? Yes No
# of Seasons?
Date of Birth:
Camp Schedule: August 4-8, 2013
Mailing
Address:
Ages: 4 - 7
Ages: 7 - 14
8:30am - 11:30pm
9:00am - 12 noon
Camp Location: Lotus Park Baseball Fields
Sponsor:
Mother Lode Church:
Phone # ( ) 870 Beach Ct., PO Box 1023, Lotus CA 95651
(530) 622-0686
Email Website: www.motherlodechurch.com
Email: [email protected]
Emergency Contact: Name Phone # ( )
Alternate # ( )
T Shirt Size:
Registration Fee: $30.00 In Advance $35.00 At Park
2014 MLC Soccer Camp Registration Name: Last First Date:
First Time? Yes No
# of Seasons?
Date of Birth:
Camp Schedule: August 4-8, 2013
Mailing
Address:
8:30am - 11:3
9:00am
Camp Location: Lotus Park Baseball Fields
Sponsor:
Mother Lode Church:
Phone # ( ) 870 Beach Ct., PO Box 1023, Lotus CA 95651
(530) 622-0686
Email Website: www.motherlodechurch.com
Email: [email protected]
Emergency Contact: Name Phone # ( )
Alternate # ( )
T Shirt Size:
Registration Fee: $35.00 In Advance $40.00 At Park
2016
July 11th-15th, 2016
$40.00 $45.00
Ages: 5-8
Ages: 9-13
9:00 - 11:30 am
9:30 - 11:45 am
MLC Permission Slip & Medical Release Mother Lode Church (530) 622-0686
870 Beach Court - PO Box 1023 - Lotus, CA 95651
Please Print Clearly
Participant’s Name:_________________________________ Birth Date:_____________
Parents/ Guardians Names (for minors only):
__________________________________ __________________________________
Mailing Address:___________________________________________________________
City:______________________ State:______ Zip___________
Hm. Phone:___________________ Wk /cell Phone: _____________________
Medical Insurance Company: ________________________________________________
Policy number _____________________
In case of emergency, please notify:
Name: ____________________________ Phone #:_____________________
Health history: ___ Allergies ___Asthma ___Diabetes ___Heart Condition
___Epilepsy/ Nervous System Disorder ___ Other
If you have checked any of the above, please give details (use the back for more room):
_______________________________________________________________________
_______________________________________________________________________
Date of last tetanus shot: ______________
Activity restrictions - (Use the back for details.)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
This health history is correct, so far as I know. I hereby give my permission to the licensed physician, nurse or medical care provider designated by the group leader to secure medical aid as required for illness or injury under a physician's orders, including transportation to and from the necessary facilities. I understand that I will be billed for any professional services rendered. I do hereby release Mother Lode Church, its officers, its employees, agents and members of its Board from all claims and causes of action by reason of an injury, which may be sustained as a result of these church activities. The above information is true and I give my consent as parent and/or guardian for my child,
(child’s name) ______________________________________________ to participate in the
Mother Lode Church Kids Soccer Camp from July 11-15, 2016.
Parents/Guardians signature: __________________________________ Date:___________
