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Student's Name First Last
Age
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Number ### - ### - ####
Email
Parent/Guardian's Name First Last
Emergency Contact Phone Number ### - ### - ####
Special Needs/Allergies
The following consent form must be signed on your first day of camp.

I hereby consent to let my child named above participate in the West River Road Baptist Church Soccer Camp of 2009. It is understood that every precaution will be taken for the safety and well-being of my child, but in the event of accident or sickness, West River Road Baptist Church, its staff, and its volunteers are hereby released from any liability.
I agree I disagree
Do Not Fill This Out

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