Soccer Camp *Denotes Required Field * Title AIA Soccer Camp 2019 July 22-26 Bakerview Park 1845 154 Street, Surrey9am-3pm • Ages 7-12COST: $130 Our university and college soccer players help your child develop fundamental soccer skills. Each day includes exciting competitions, fun fitness, and amazing tournaments. Every camper gets the individual attention they need to grow as a whole person. Please complete a form for each child. To register more than one child (up to 4), after submitting payment, navigate back to the registration page through the site menu. Do not use the "back arrow" in your browser. * Child's Surname * Child's First Name * Gender Female Male * Street Address * City Please select an option Surrey Delta White Rock Langley Vancouver Province Please select an option B.C. * Postal Code * Date of Birth (mm/dd/yr) * Age * Grade Entering in September 2018 Parent/Guardian Information * Parent or Guardian Name(s) * Email * Phone/ Cell ( ) - Other Phone ( ) - * Emergency Contact (if parent or guardian is not available) * Emergency Contact Phone Number Medical Information * Care Card Number * Doctor's Name * Doctor's Phone Number Please indicate if your camper has ever had or currently has: Head Injuries Seizures Neck/back disorder Fainting spells Psychiatric disorder Eye problems Glasses/ contacts Nose bleeds Dental problems Ear problems Asthma Bronchitis Please indicate if your camper has recently (within one year) experienced the following: Infectious disease Head injury Major surgery Traumatic or overuse injury Allergies Fractures Operations * Date of tetanus/booster (mm/dd/yr): Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Current non-prescribed medications (date completed) Current prescribed medications (date completed) Please list any other health problems or relevant information, or explain any of the conditions above marked "yes" Your child's health information is collected in case of emergency and to ensure the safety and well-being of each person involved in our camp ministry. This information will only be seen by PPAC Children's Ministry Pastors and our Camp Staff and will be kept in a secure place. Church Information * Home Church Peace Portal Alliance None Other Friends I've Invited to Kids Camp (Name & Grade) T Shirt Size Youth Medium Youth Large Adult Small Adult Medium Adult Large Consent and Authorization In consideration for being accepted by Peace Portal Alliance Church for participation in AIA Soccer Camp 2018, I (we) do hereby release and agree to hold harmless the church, its directors, employees and agents from any liability, claims for personal injury, sickness or death, property damage and expenses, of any nature whatsoever which may occur while participating in Kid’s Camp. I (we) also hereby authorize the staff of AIA Soccer Camp 2018 to make any and all decisions regarding the emergency treatment of my child. I (we) understand that it is my responsibility to drop off my child at the field by 9:00 am and that my child will be dismissed at 3 pm for pick up. I (we) will abide by the security procedures set in place by the church and its directors. I (we) also understand the church and its directors may use photographs and video taken during AIA Soccer Camp 2018 for ministry promotion at Peace Portal Alliance Church, online and on our social media pages. I (we), the Parent/Guardian, have read, understand and agree with the above by entering my full name and clicking 'yes'. * Waiver Agreement Yes, I agree No * Please enter your full name * Date Rates: $120 before July 1st. $130 after July 1st. If you are registering more than 1 child from the same family, the rate is reduced by $10. Please note that the last day for refund is July 9th. I consent to receive email notices and the Peace Portal News. I can unsubscribe at any time. Credit Card Payment click continue and complete the secure Payment Form Cheque Payment click continue and disregard the Donation Form. Please make your cheque payable to Peace Portal Alliance Church and mail or bring to the office (15128 27B Ave Surrey BC V4P 1P2). Note: Your registration is not confirmed until payment is received.
