First Name		Last Name
Address		City/State/Zip
Home Phone		Date of Birth
Email Address
Payment Info	Check - Please make payable to UMass Lowell Soccer
	Credit Card - May we call you for your credit card number?         Yes          No - I will call you
I wish to sign my child up for the following session(s): Please note: 10% discount for returning day campers, children of UML faculty/staff, UML Kids Club members.  Groups of 10 or more receive an additional 10% off.
	High School Training I (July 21-24)		$150
	High School Training II (July 28-31)		$150
	High School Training Combo (Weeks 1&2)		$275
T-Shirt Size	Youth:M   L       Adult: S   M    L    XL
Insurance Information
Parent(s) Name(s)
Date
Insurance Co.
Policy #:
Group #:
Please list any allergies or medications:
Emergency Contact
Contact Phone #
Please list any allergies you have
The UMass Lowell Soccer Clinic, its directors, staff and associates assume no responsibility for accidents and medical or dental expenses incurred as a result of participation in this sports clinic.  All participates must submit their insurance company's name to be admitted.  In case of emergency, I authorize the UMass Lowell Soccer clinic to arrange the necessary medical treatment for my child.           I accept.           I do not accept.
If you are mailing in your information, please mail to: UMass Lowell Soccer Clinic, Men's Soccer Office, One University Avenue, Lowell, MA 01854.  For further information, please call Coach Ted Priestly at 978-934-2317.