SOCCER CAMP APPLICATION

Please complete this form and return it to:

Janice Sturchio, PHS Soccer Booster Club President

526 Dori Place

Stewartsville, NJ 08886

Phone: (908) 213-3577

Phillipsburg Soccer Day Camp Cost: $170.00 per player. Deposit of $50.00 due with form. Questions can be sent to PHSSOCCERBOOSTERS@Yahoo.com Checks payable to PHS Soccer Boosters

Date: Monday June 27^th to Friday July 1st

Time: 9 AM to 3 PM

Where: Phillipsburg Christian Academy Soccer Field on Belvidere Ave

Coaching will be lead by Vision Training. Camp is exclusively for PHS High School students (incoming freshmen through returning seniors)

Camper’s Name _________________________________________ Male Female

Home Address _______________________________________________________________

City _______________________________________ State ____________ Zip____________

Home Phone ( ) ___________________ Campers e-mail __________________________

Date of Birth ________________________ School _________________________________ Grade in 2005/2006 School Year _________________

Name of father _________________________________ Work phone ____________________ Home or Office e-mail _________________________

Name of mother ________________________________ Work phone _____________________ Home or Office e-mail _________________________

Emergency Contact ______________________________ Phone # _______________________

Insurance Co. ___________________________________Policy # _______________________

Physicians Name _________________________________Phone # ______________________

Special Concerns _______________________________________________________________