Registration Form: Please Print all information and return with payment to: Rose Soccer – CM 41 5500 Wabash Avenue Terre Haute, In 47803 Name Address City _ State Zip Grade in Fall School/Team Name _ Position Shirt Size _ Parent/Guardian Information Name Address City _ State Zip Phone Number Email Summer 1/2 Day Soccer Camp Release on Medical Treatment Dates: June 18-22, 2018 In consideration for my son/daughter's participation In the 2018 Rose-Hulman Institute of Technology (RHIT) Youth Soccer Camp, I hereby agree and promise that I will not hold Rose-Hulman Institute of Technology or its employees responsible for any loss, damage, or personal injury that he/she may occur as the result of participation in the camp Venue: Jim Rendel Field Where: Rose-Hulman Grade in Fall: 4-8 Time: am – 11:30 am each day Cost: $100 * Make Checks out to Rose Soccer Daily Schedule: 8:45 am – Drop off campers – 9:30 am – Warm up games 9:30 – 10:15 am – Skills practice 10:15 – 10:30 am – Break 10:30 – 11:25 am – Small Sided games 11:30 am – Pick up campers Staff: Rose-Hulman coaching staff and current players Boys Contact: Sean Helliwell Helliwel@rose-hulman.edu (812)-877-8461 Girls Contact: Amy Helliwell Helliwe8@rose-hulman.edu (812)-877-8539 Camper Name _ Parent/Guardian Signature Date In case of emergency, contact me at the following phone number(s): work cell _ Home _ Authorization of Treatment: I hereby give permission to the trainer/ physician selected by camp to provide the treatment for my child while attending the RHIT Youth Soccer Camp Parent/Guardian Signature Date ... Day Soccer Camp Release on Medical Treatment Dates: June 18-22, 2018 In consideration for my son/daughter's participation In the 2018 Rose-Hulman Institute of Technology (RHIT) Youth Soccer Camp, ... am – Pick up campers Staff: Rose-Hulman coaching staff and current players Boys Contact: Sean Helliwell Helliwel @rose-hulman. edu (812)-877-8461 Girls Contact: Amy Helliwell Helliwe8 @rose-hulman. edu... hereby give permission to the trainer/ physician selected by camp to provide the treatment for my child while attending the RHIT Youth Soccer Camp Parent/Guardian Signature Date