Logo goes here - SoccerPlus Camps

M
F
Immunizations or proof of illness
Relationship:
Group #
Date
Individualized Order Form for ALL medications MUST also be completed.
Check those that apply:
Life Threatening Conditions
 Contact Lenses
 Ear Aches / Infection
 Asthma
 Gyn Problems
 Poison Ivy, Oak, Sumac
 Diabetes
 Rheumatic Fever
 Stomach Problems
 Epilepsy / Seizures
 Sore Throat
 Absence of a paired organ
 Heart Conditions / Murmur
 Whooping Cough
 Sinus Problems
 Food Allergies (specify)
 Current orthodontic
 Mononucleosis in the past 12
 Medication Allergies (specify)
appliance
months
 Skin Problems (Acne,
 Recent Illness / Infections
 Other Allergies ~ insect stings,
Eczema)
hay fever, animal
 HBP
 Concussion / Head Injury
 Other (Please detail)
 Bone / Joint Injuries
 Other Chronic Condition
 Operations
 Other
* * * Details of above to be completed on additional sheet * * *
Health History:
We recommend that a photocopy (front and back) of health insurance card be attached to this form.
Ins. Co.
Policy #
Insured Employer
Medical Insurance Company (REQUIRED)
Printed Name
Signature of Parent/Guardian
Indemnification: The undersigned parent/guardian of the registrant, for and in further consideration of SoccerPlus Camps’ accepting
said registrant, hereby agrees to save and indemnify and keep harmless the said SoccerPlus Camps, its agents, and sponsors
against any and all liability, claims, judgments, or demands arising as a result of any course of instruction or activity given the registrant
by SoccerPlus Camps.
Parent/Guardian Authorizations: This health history is correct and complete. The person herein described has permission to engage
in all camp activities except as noted. I hereby give permission to the camp to provide routine healthcare and seek emergency medical
treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for treatment, referral, billing, or
insurance purposes. I give permission to the camp to arrange necessary related transportation for me/my child. In the event I cannot be
reached in an emergency, I hereby give permission to the Director of SoccerPlus Camps or their designee to secure and administer
treatment, including hospitalization, for the person named above.
)
Date
Date
Weight
Vision (R / L)
Respiratory
BP
Extremities
Skin
Please submit at least 30 days prior to camp
and also bring originals to camp:
Submit Form Electronically to:
[email protected] /Fax 888-891.4474
SoccerPlus has gone paperless. We will
no longer accept paper copies via mail.
Date:
Examining physician:
Telephone: (
)
Print physician’s name:
State licensed in:
License #:
Address:
RECOMMENDATIONS:
The above named person is in satisfactory condition and may engage in all
camp activities except as noted:
RESTRICTIONS, LIMITATIONS (INCLUDING DIET):
Height
Hearing (R / L)
Dental / Bite
Cardiac
Hernia
Genitals
Physical Examination: - Valid for 365 Days Only and to Be Completed
by a Licensed Health Care Professional ONLY!
Measles
German measles
Mumps
Hepatitis A
Hepatitis C
Illness (if applicable)
Zip:
Gender:
Boosters
Immunizations
Contact:
Phone: (
State:
/
Date
Varicela or proof of Chicken Pox
)
)
/
Dtap/TD/Tdap
Polio (3)
Hepatitis B (3)
MMR (2)
TD (valid 10 y)
Haemophilus
Influenza Type B
Immunizations
In Case of Emergency and parent / guardian cannot be reached:
Age at camp
Birth Date:
Address:
City
Phone Number (Day): (
(Eve):
(
Student Name
Camp Code:
(completed by staff)
Send a copy – and also bring the original forms to camp!
PLEASE COMPLETE ENTIRE FORM
Immunization and Physical form from school / physician may be submitted in lieu of
completing the immunization and physical examination section below.
Authorization for the Self-Administration of Medications
CAMPER:
DATE OF BIRTH:
/
/
WEIGHT:
lbs
This person takes NO medications on a routine basis.
The following form must be completed and signed by the child’s physician if your child:

Needs to take any Over the Counter Medication “as needed” provided by the parent /guardian, while at camp. (Part I)
Over-The-Counter medication must be in the original container and labeled with the child’s name.

Needs to take any routine Prescription Medications, provided by the parent /guardian, while at camp. (Part II). Prescription
medications must be in pharmacy-prepared containers and labeled with the name of the child, name of the drug, strength, dosage,
frequency, physician’s or dentist’s name and date of the original prescription.
ALL MEDICATIONS AT CAMP ARE TO BE SELF-ADMINISTERED, BUT KEPT BY THE MEDICAL STAFF WHILE ON SITE.
Part I - Over-the-Counter Medications
Drug Name
Tylenol
Route
Liquid or Tabs
Dosage
Per Label
Indications
Pain or Fever
Physician Order
Yes No
(EXAMPLE)
(EXAMPLE)
(EXAMPLE)
(EXAMPLE)
(EXAMPLE)
Comments
Part II - Prescription Medications
Controlled
Substance
Drug Name
Route
Dosage / Time of
Administration
Indications
Physician
Order
Comments / Relevant Side
Effects
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
If there are Relevant Side Effects listed above, please provide plan for management for each substance.
Date:
Telephone:
Examining physician:
(
)
Print physician’s name:
License #:
State licensed in:
Authorization by Parent/Guardian for the administration of the above medication:
To nurse, first aider, director, alternate director or youth camp counselor: I hereby request that the above medication, ordered by the physician/dentist
for my child
, be administered by the nurse, first aider, director, alternate director or youth camp counselor.
I understand that I must supply the Youth Camp with the prescribed medication in the original container dispensed and properly labeled by a physician
or pharmacist. Over-the-counter medication shall be in the original container labeled by the parent with the child’s name. I understand that this and all
medication will be destroyed if it is not picked up on the last day of camp following termination of the order.
Name of Parent or Guardian
Street Address
Relationship to child:
Signature
(Print Name)
City/Town
State
Date:
/
Phone (
/
)
Tel– 800.KEEPER.1
Fax 888-891-4474
soccerplus.org
Individual Information
Last Name
Birthdate
First Name
Gender: Male / Female (circle one)
Grade
Address (Street, City, State, zip)
Home Phone
Mother Cell Phone
Father Cell Phone
E-Mail
AMATEUR ATHLETIC WAIVER AND RELEASE OF LIABILITY
In consideration of being allowed to participate in any way and/or enter upon, use and/or engage in sports activities by SoccerPlus
Companies: SoccerPlus Camps, Inc, including participation in practices, training, programs and/or other events and activities, the
undersigned:
1. Agrees that prior to participating, he/she will inspect the facilities and equipment to be used, and if he/she believes an ything is
unsafe, he/she will immediately advise a representative of SoccerPlus of such condition(s) and refuse to participate;
2. Acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including
permanent disability and death, and severe social and economic losses which might result not only from their own actions,
inactions or negligence of others, the rules of play, or the condition of the premises or of any equipment used. Further, that there
may be other risks not known to us or not reasonably foreseeable at this time;
3. Assume all the foregoing risks and accept personal responsibility for the damages following such injury, permanent disability or
death;
4. Release, waive, discharge and covenant not to sue SoccerPlus, or their affiliated clubs, their respective members, administrators, directors,
coaches and other employees of said organizations, participants, sponsoring agencies, sponsors, advertisers, and, if applicab le, owners and
lessees of premises used to conduct the event, all of which are hereinafter referred to as “releasees”, from demand, losses or damages on
account of injury, including death or damage to property, caused or alleged to be caused in whole or in part by the negligenc e of the
releasees or otherwise;
5. Shall defend, indemnify, and hold SoccerPlus Companies: SoccerPlus Camps, Inc., its officers, employees, and agents harmless from and
against any and all liability, loss, expense, including reasonable attorneys’ fees, or claims for injury or damages arising out of the
performance of this Agreement but only in proportion to and to the extent such liability, loss, expense, attorneys’ fees, or claims for inj ury
or damages are caused by omissions of the individual or group obtaining services from the SoccerPlus Companies, its officers, agents or
employees;
6. Agrees to allow SoccerPlus to utilize the likeness and image of the participant in the form of photographs and/or video for the purposes of
marketing and/or promotions.
THE UNDERSIGNED HAVE READ AND ACKNOWLEDGE THAT HE/SHE IS ENTERING INTO THE ABOVE WAIVER AND RELEASE, UNDERSTANDING
THAT THEY HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGN IT VOLUNTARILY. WITHOUT LIMITING THE GENERALITY OF THE
FOREGOING, IT IS MY INTENTION ON BEHALF OF MYSELF OR MY MINOR CHILD TO SPECIFICALLY RELEASE AND SOCCERPLUS CAMPS, INC. FROM
ANY AND ALL CLAIMS ARISING FROM THEIR OWN NEGLIGENCE. I AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS SOCCERPLUS CAMPS,
INC. FROM ANY LIABILITIES, LOSSES, DAMAGES, SETTLEMENTS, CLAIMS, EXPENSES AND COSTS ARISING FROM MY OR MY CHILD’S
PARTICIPATION IN THE DESCRIBED ACTIVITY, SAID INDEMNITY TO INCLUDE COURT COSTS AND REASONABLE ATTORNEY’S FEES.
Individual Signature (18 or over)
_Date
Guardian Signature (if minor)
Date
Tel– 800.KEEPER.1
Fax 888-891-4474
soccerplus.org
RULES & REGULATIONS:
Please read, review and understand all content on these two pages. It is your responsibility to abide by all rules and
regulations at all times.
Roommates:
Roommates must each request each other by full name for the
request to be considered (student A requests student B and viceversa).
Once at site, no one can change room assignments without
permission of the director.
Some sites only offer only multiple beds per room. We will do
everything that we can to honor roommate requests. There are
circumstances outside of control that may limit our ability to fulfill the
request.
Travel Arrangements:
SoccerPlus will pick up and drop off students only during select
times from only the designated airport.
To arrange for the shuttle service: please call ATP International
Travel Service at 1-800-243-1806 or 203-772-0060 and ask for “The
Soccer Desk.” This is the only way a student can reserve a spot with
this shuttle service.
They can make your flight arrangements, coordinate the arrival and
departure times and schedule your shuttle with SoccerPlus for a $50
fee. If you book the flights by yourself you must provide the student's
itinerary to ATP and not the SoccerPlus Office, so they can add the
student to the camp itinerary.
Reservations for shuttle must be made at least 15 days prior to the
start of camp. Reservations made within 15 days of the camp may be
subject to an additional charge.
Driving directions to camp will be included in your pre-camp email, sent approximately one week before the camp start date.
Campers may not arrive earlier than the first day of camp at 3:00
PM and must leave on the closing day by noon.
Medical Policies:
1. Detailed Medical documentation policies and other policies (health
care, discipline, and grievance) are available upon request [MA
430.215] by sending a self-addressed stamped envelope to the
SoccerPlus Administrative Office.
2. All medications will be self-administered at camp, but kept by the
staff certified athletic trainer (ATC) in a lockbox.
3. All medication use MUST accompany an Authorization for the SelfAdministration of Medications form, available from our website or from
our office. This must be completed and signed by physician PRIOR to
the start of the program.
4. If you’ve had a recent physical and would like to attach a copy of
your signed and dated physical form to our form, you may as long as
you fill out the left-hand side of our health form as well. These forms
are acceptable as long as the physician’s signature and date are less
than one year old on the last day of camp.
OUR PURPOSE AND YOUR INTENTIONS ARE TO DEVELOP
YOUR SOCCER SKILLS. THE FOLLOWING RULES HAVE BEEN
ESTABLISHED TO HELP US BOTH REACH OUR GOALS. THEY
WILL BE ENFORCED.
1. Specific campus rules must be adhered to. Remember we are
guests of the particular school and must respect their property and
regulations.
2. Students that drive to camp must turn in their keys to the director,
and inform camp personnel of the location of the vehicle. Use of the
car will be forbidden during the camp week.
3. Students are not allowed in campus areas held off limits to
SoccerPlus Camps. IMMEDIATE DISMISSAL MAY RESULT! No one
is allowed to leave campus grounds without the permission of the
director of SoccerPlus.
4. POSSESSION OF ALCOHOLIC BEVERAGES, DRUGS
INCLUDING TOBACCO, FIREARMS, OR ANY ITEM DANGEROUS
TO OTHER STUDENTS WILL RESULT IN IMMEDIATE DISMISSAL
AND POSSIBLE CRIMINAL PROSECUTION.
5. Tampering with fire safety equipment, electrical wiring or any
campus property may result with dismissal.
6. Rooms must be kept clean and neat. Students are responsible for
broken or damaged items. Before dismissal at end of camp rooms will
be inspected.
7. Students must secure their valuables. SoccerPlus is not responsible
for any lost valuables.
8. No student is allowed in another student’s room without an
invitation.
9. Girls’ dormitory hallways and rooms are off limits to all males and
vice- versa. Violators will be IMMEDIATELY DISMISSED.
10. The daily schedule of the program is to be adhered to, including all
meeting times, meal times and wake-up and lights out.
11. Shinguards are mandatory at all training sessions.
12. An athletic trainer will be available at all camp locations. If special
treatment is necessary, SoccerPlus must be informed in writing prior
to the first training session. All injuries must be reported to the athletic
trainer or camp director.
13. Any student dismissed from camp for disciplinary reasons will not
be entitled to any refund.
Refund Policy:
The deposit of $250 is non-refundable.
Any monies paid beyond the deposit amount are completely
refundable until 30 days prior to the start of the program. At 30 days
prior to start of programs, no refunds will be issued, only credit to
future programs.
Credits are transferable to immediate family members.
All refund requests must be made in writing and can be emailed to
[email protected].
We reserve the right to handle all refunds on an individual basis.
OUR ADVICE: Concentrate on soccer and the SoccerPlus Camp experience will be worthwhile,
rewarding and enjoyable. If you have any questions please call our office at 1.800.533.7371
Monday through Friday 10am to 5pm eastern time or email us anytime at [email protected]
Tel– 800.KEEPER.1
Fax 888-891-4474
soccerplus.org
What to Bring:
Attending SoccerPlus Camps this summer will benefit anyone who is looking to improve their game. It is an experience unlike any other which will
change your life on and off the field. However, to make the most of your camp experience, you need to be fully prepared. Here are some tips that will
help.
1. BE PHYSICALLY PREPARED
Come to camp in your best physical condition to get the most out of the time at
camp. Every moment at camp is a valuable learning experience so be fit enough
to participate. You want to be able to seize every opportunity to practice and learn.
Our ability to pay attention decreases when we are tired. Our ability to train is
reduced with a pulled muscle. The bottom line is that to take full advantage of
everything that is offered at camp you must be in good physical shape.
2. THE RIGHT EQUIPMENT
Bringing the right equipment is crucial to having a successful camp. Please make
sure that you bring:
A lanyard for your dorm keys and cafeteria pass (optional but recommended)
Cleats that are already broken in. Don’t buy a new pair of shoes to wear at
camp unless you have enough time to break them in. New shoes can give you
blisters.
Indoor/flat shoes for possible indoor sessions and casual evening wear.
Sometimes because of bad weather sessions will be conducted indoors.
A ball. One can be reserved for you by prepaying $25 at least 2 weeks prior to
camp. Call 800-533-7371 or e-mail [email protected] to reserve a camp ball.
Shinguards. Note: Please bring your own athletic tape if you need to hold your
socks up. Our athletic trainer’s tape is for injuries only.
A warm-up suit/sweats. You don’t want to get cold on your way to the evening
lecture.
Plenty of t-shirts, shorts, socks and underwear. SoccerPlus dress code
forbids mid-drift tops or sleeveless shirts, for both boys and girls.
Sheets (standard twin), blankets, pillow and towel(s).
Bathroom items e.g. soap, shampoo, toothbrush, toothpaste, deodorant, etc.
Sandals for the shower.
Laundry detergent – Laundry is optional, but available.
A bathing suit Some camps have access to a swimming pool.
An alarm clock. All meals and meetings are mandatory.
A fan. Not all rooms are air-conditioned.
A notebook and pen for evening workshops.
Bug spray and sun screen.
A calling card or cell phone so you can call home.
Spending money for evening snacks, laundry or the camp store. Sorry, there
is no camp bank. The camp store does accept credit cards.
A water bottle of your own which can be refilled from our coolers on the fields.
This is a must.
An address book. The friendships you make can last a lifetime.
A disposable camera to get photos with your new friends.
GOALKEEPERS:
In addition to the above also bring:
Extra goalkeeper jerseys. W e recommend 4 or more. Long sleeve t-shirts
also work well.
At least one pair of goalkeeper gloves.
Long goalkeeper pants for breakaway sessions.
Skids or compression shorts work well but we suggest long pants for
breakaway training.
There may be some other things you can think of but if you bring all of the above
you will be in good shape. Don’t forget, there will be a camp store at each site with
a great selection of equipment.
3. TAKE GOOD NOTES
Evening workshops are designed to present students with information which time
does not permit during the day. Most students are pretty tired by the end of the
day but this is not the time to zone out or doze off. If you take good notes it will
help you to pay attention and you will have a valuable asset to review when camp
is over. It is also a good idea to jot down some of the exercises you did during the
day. By the end of the week it will be hard to remember all that you have done.
4. TALK TO THE COACHES
Most coaches were students at some time in the past. They can relate to a lot of
issues which concern you. Never be shy about talking with coaches. They are
there to help you. Many students develop lifelong relationships with their staff
coaches. Exchange phone numbers, emails and addresses so you can stay in
touch during the season.
5. STAY POSITIVE
A week can be a long time when you are training with intensity. There will be
some high and low points. It is important that you minimize your low points and get
back on track quickly. Ultimately, you will learn more and have more successes
with a positive state of mind.
6. BE A SPONGE
Probably the most important thing you can bring to camp is an open mind. You
are about to be inundated with all types of technical, tactical, psychological and
physiological information. No matter how good you are or how many successes
you have enjoyed remember why you decided to go to camp...to get better by
learning from the best. Camp is a learning environment like school. You are
presented with a whole lot of information and then it is up to you to decide what to
do with it. Your goal should be to absorb as much information as possible and
then fit what you can into your game. You may not agree with everything but you
owe it to yourself to open your mind and try new things. Remember why you
signed up for camp.
7. THE NEVER ENDING CAMP
Camp does not end at the end of the week. The improvement will continue
throughout the year if you continue to apply what you learned at camp. Remember
the exercises you did (hope you took good notes), the intensity level at which you
worked, the discipline you showed on and off the field and the words of wisdom
you picked up from the staff. Every time you step on the practice field you should
relive your week at camp. You have been given the tools to make yourself a better
player. By the end of the week you will be a better player, but why should the
improvement stop there.
Enjoy your time at camp this summer. Strive to make the most of it as humanly
possible and you will reap the rewards for the rest of your life
.
Please remember that registration begins at 3 pm. The first meal served at camp
will be dinner. Try to eat lunch prior to registration so you will have the energy for
our first field session. (If you are flying in, bring a bagged lunch, if you are driving
in, pack a lunch or pick up something locally when you arrive).
“This Program is tough and intense. Those who attend our school become part of a very special
family. The skills, friendships and self-respect you gain here will last a lifetime.” – Tony DiCicco