Soccer Event Registration for: Summer Camps

Player Information Parent Information
First Name:
Last Name:
Phone: (999-999-9999)
Gender: Male:   Female:
Date of Birth: (mm/dd/yyyy)
Current grade in school:
June - Under 4 - Under 8 Futures Summer Camp ($85):
July - Under 4 - Under 8 Futures Summer Camp ($85):
First Name:
Last Name:
If address is different than Player, please fill in address:
Phone: (999-999-9999)
Cell Phone: If no cell phone, then enter n/a.
Email Address:
Confirm Email Address:
Shirt Size: Youth Small   Youth Medium   Youth Large   Adult Small   Adult Medium   Adult Large    
Please check this box - I wish to pay the above fees by credit card
  Or I will be mailing a check .
Emergency Information
Emergency Contact:
Emergency Phone:
Health Insurance Name:
Physician Name:
Physician Phone:
Health Insurance Policy #:
List any medical conditions, previous concussions, or prohibitions player has (please include allergies) :

Parent’s/Guardian’s Consent

The player registrant named above has my permission to participate in the Hempfield Soccer Club, Penn Legacy camps programs.  In consideration of your acceptance of my enrollment, I, the player and we, the parents/guardians, individually and collectively, intending to be legally bound, hereby for ourselves and our heirs, executors and administrators waive and release the Hempfield Soccer Club, Penn Legacy, and facility owners, their agents and representatives, from any and all claims or rights to damages for injuries or losses suffered by me the player, directly or indirectly, in training for, or traveling to and from, or competing in or while attending any future Hempfield Soccer Club, Penn Legacy camps functions.  I acknowledge that the registration and or registration fee does not include accident insurance coverage.  I consent for medical treatment for my child in the event of an emergency.


I, the parent/guardian of the registrant, a minor or adult registrant of legal age, agree that I and the registrant will abide by the rules of EPYSA and the Hempfield Soccer Club, Penn Legacy Camps, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer, and in consideration for the EPYSA and Hempfield Soccer Club, Penn Legacy Camps accepting the registrant for its soccer programs and activities (the “Programs”).  I hereby release, discharge and/or otherwise indemnify the EPYSA, and Hempfield Soccer Club, Penn Legacy and its affiliated organizations and sponsors, their employees and associated personnel, including owners of fields or facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrants participation in the Programs, and/or being transported to or from the same which transportation I hereby authorize.

Concussion Release

Penn Legacy/EPSYA Policy on Concussion Procedure and Protocol:

Go to this site and read the concussion fact sheet for parents/guardians:

Your electronic signature below (after the 'S/:' below) indicates that you have read and fully understand the Consent, Release, Policy and Concussion Release above and its terms, and consent to be bound.

Please enter your First and Last Name S/:

 and I have provided correct information for registration.

You will receive a pop-up of this completed form after submitting. Please print and bring to first date of this event. Checks should be made payable to Penn Legacy, P0 Box 216, Landisville, PA 17538

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Please wait for window with completed form to appear - then print 2 copies.
one for your receipt and one to sign and bring to the first session. A copy will also be emailed to you. (shirts may not be available for those registering after the deadline)