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| This completed form will enable health facilities and Honduran Soccer Camp staff to provide prompt care to your minor son or daughter. | ||
| All Areas of This Form Must Be Completed Prior to Camp Participation | ||
| Camper’s Name | ||
| Social Security # | ||
| Birth Date | ||
| Guardian’s Name/Relationship | ||
| ______No _____Yes Allergic Reactions (drugs, food, asthma…)____________ | ||
| ______No ______Yes Taking any medication at this time __________________ | ||
| If yes,
please describe Date of last tetanus toxoid ________________________ |
||
| In Case of Emergency Contact: | ||
| Father Home Telephone | ||
| Father Work Telephone | ||
| Mother Home Telephone | ||
| Mother Work Telephone | ||
| Other Emergency Number (List person to contact) | ||
| Your Insurance Company | ||
| Policy # | ||
| Name of Policy Holder | ||
| Any instructions regarding your insurance | ||
| I/We, the
undersigned, for ourselves and as the guardian’s of
Camper’s Name ___________I/We, the undersigned
hereby certify that I (we) am (are) the parent or legal
guardian of the camper. I hereby give permission for the
staff of the camp to seek during the period of the camp
appropriate medical attention for the camper and for
medical attention to be given and for the camper to
receive medical attention in the event of accident,
injury, or illness. I (we) will be responsible for any
and all costs of medical attention and treatment, except
for that covered by the camp’s excess medical
coverage policy.understand that soccer is an active,
physical sport, and that injuries can take place during
play. I/We also understand that there will be a number of
children attending the camp, there will be a limited
number of coaches and/or counselors, and that our child
can not receive individualized attention and supervision
all of the time. I/We understand that, as with any sport,
injuries can occur, and we hereby acknowledge that our
child is physically fit and mentally capable of
participating in soccer and Academy activities. I/We, represent that I/we have
sought the opinion of our child’s pediatrician (Name
of Camper’s Physician) ,_________, and he concurs
that )Camper’s Name) , _______________________ I/We also understand that it is my/our responsibility in caring for the camper listed above, and to be assured that he/she is fully capable of engaging in this sport’s activity, and I/we are confident that he/she is able to engage in such a sport. I/We, the undersigned for
ourselves, our heirs, executors and administrators,
waive, release and forever discharge Dr. Carol Cross,
ISAI, and Honduran Soccer Camp and its staff, officers,
agents, employees, representatives, successors, and
assign of and from all rights and claims for damages,
injury, or loss to person or property which may be
sustained or occur during participation in camp
activities or while at camp, whether or not damages,
injury, or loss is due to negligence. Signature of Parent or
Guardian ___________________________________ |
||
| Return To Camp Application Return To Honduras Soccer Camp Page Print this application and mail with application to Mail to: International Sports Adventure Institute, Inc Dr. Carol Cross 5102 N. 60th Drive, Glendale, AZ 85301 |
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More information on Soccer is available to you from exportfacs@aol.com. Our Soccer Entry web site is http://home.earthlink.net/~itidc/soccer_entry.htm
Information on soccer sponsorship and marketing partnerships can be found at http://www.satglobal.com/sponac3.htm and http://www.satglobal.com/tapwahs.htm
Get Information on Soccer Against Global Warming Tournament in Hondurastoday by emailing Dr. Carol Cross at exportfacs@aol.com .
In Honduras contact:
Dr.
Ramon Dario Argueta
Barrio El Morera, Frente Bazar Reyna
La Esperanza, Intibuca, Honduras
Telephone 504-783-0054
Dr. Cross Can Be Reached In Honduras after July 1, 2005 Mailing Addresses after July 1, 2005 - Dr. Carol Cross, C/O Doña Aleja de Valdivieso, Barrio El Centro, La Esperanza, Intibuca, Honduras exportfacs@aol.com or honducopa@yahoo.com Telephone 504 - 783 - 0421 You May Also Contact Dr. Cross Through Doña Silvia Palencia y Hijos, Hotel La Esperanza, La Esperanza, Intibuca, Honduras Telephone 504 - 783-0068 Through Dr. Ramon Dario Argueta, CODET, Barrio El Morera, Frente Bazar Reyna, La Esperanza, Intibuca, Honduras, Telephone 504-783-0054 Email honducopa@yahoo.com The International Institute of Soccer Tourism Is Opening in La Esperanza, Honduras in September 2005. IIST Understands The Problems of Soccer Tourism in Developing Countries. IIST Supports Soccer Tourism Professionals in Central America, South America, the Caribbean Islands, Africa and Asia |
ISAI Contact Information
Dr. Carol Cross, Director , The International Sports Adventure Institute, Inc.
Supporting Soccer Based Development Through Soccer Tourism, Honduras Soccer Camps, Intibuca International Youth Tournament, AfroCarib International Youth Tournament, the Copa Weshemisphere Friendlies and the LigaAmericás Soccer Mastery Academy. AfroHeritage Soccer Players - Join the RED de AfroHeritage Footballers. AfroHeritage Soccer Players - Play in the African/Caribbean Youth Soccer Tournament in November 2005. Learn to Play World Class soccer in the La Ceiba Football Academy for Elite Players Opening in June 2005 in Honduras. Email to exportfacs@aol.com
Soccer is our Passion, Our Love, and Our Focus at ISAI. We work with Youth At Risk in Arizona and Honduras through our support for Soccer For Life, Inc, a a public charity and 501 (C) 3, tax exempt, non profit organization. Subscribe to free Soccer Mastery newsletter based on the LigaAmericás Soccer Mastery Academy opening in 2005 in La Esperanza Honduras in La Esperanza, Honduras. Send email to exportfacs@aol.com. Play in the 2nd Torneo Internacional Intibucana "Soccer Against Global Warming" in July 2005.
Home Page: www.satglobal.com/soccer_entry.htm Email to exportfacs@aol.com or honducopa@yahoo.com
Phone : Before July 15, 2005 - 602-564-9241
After July 15, 2005 - 011-504-783-0421
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