(Please Print and Mail)

Name________________________________________________________

Address______________________________________________________

City/Town __________________________ State________ Zip ________

Phone______________ Cellular_______________ e-mail______________

D.O.B.________________ Age _________ Male_______ Female________

Position _____________________________________________________

School___________________________ Grade Entering_______________

Emergency Phone _____________________________________________

Dates Attending:

Week Of:___________________________________________________

Morning_______ Afternoon_______ Full Day______

Shirt Size: Youth-Med. ____ Adult-Med. ____ Large____ X-Large ____

Each child must show a photo copy of current insurance coverage.

Insurance Company____________________________________________

Policy #_____________________________________________________

Family Doctor ________________________________________________

Medical Authorization:

In case of emergency, I grant permission for my child to be given emergency treatment at a local hospital. I certify that my child is in good health and may participate in all camp activities.

Rhode Island Stingrays, Stingrays Soccer Camps, Mario Pereira (individually), and any all other locations or individuals associated with or working in partnership with the Rhode Island Stingrays are not responsible for accidents resulting in medical, dental or other expenses. Participants are fully responsible for any and all property damage.

Parent/Guardian Signature:________________________ Date:________

Make Checks Payable To:  Rhode Island Stingrays
501 Waterman Avenue, East Providence, RI 02914
Tel: (401) 289-2240