SF Viking Summer Camp Application

SAN FRANCISCO VIKINGS SUMMER CAMP - 2008
AUTHORIZATION OF CONSENT OF TREATMENT TO MINOR

I, (We), the undersigned parent(s)/guardians to _________________________ (player), a minor, do hereby authorize San Francisco Vikings Soccer Club, as agents(s) for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care, which is deemed advisable by, and to be rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the medicine Practice Act on the Medical Staff of any accredited hospital treatment is rendered at the office of said physician or at said hospital.

It is understood that the authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of our aforementioned agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care.

This authorization is given pursuant to the provisions of Section 2.5 of the Civil Code of California and shall remain effective until ____________________, 2008 unless sooner revoked in writing.

DATE: __________________

SIGNATURE OF PARENT/GUARDIAN ______________________________________________

PLEASE FILL OUT A SEPARATE FORM FOR EACH PARTICIPANT

Player _______________________________________________________________________________

Address ____________________________________City________________________ Zip___________

Parent's Name ___________________________________ Phone: (H) ____________________________

Email: _________________________________________ Phone: (W)_____________________________

Child's Date of Birth ________________________________ (Must please complete)

Sex: Male ______ Female _______ Emergency Phone _________________________________________

Special Instructions (i.e. allergies, medication, etc.)______________________________________________

 

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Viking Microsoccer Team or Select Team Name & Age Group:

 

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Session I -July 21 - 25; Session II - July 28 - August 1; Session III - August 4 - August 8; Session IV - August 11 - August 15

Please place a check mark next to the session(s) that you would like your child to attend.

Session #1 _________ Session #2 _________ Session #3 _________ Session #4 __________

Please place a check mark next to the time that you would like your child to attend.

______________ 9am - 4pm ______ ________ 9am- 12pm _____________ 1pm – 4pm

Extended Care: 8:30am - 9:00am; 4:00pm - 6:00pm/$30.00
Late Pick-up fee $5.00/10 minute intervals per family.
Registration Fee (before July 1, 2008): 9am - 4pm: $275.00; 9am- 12pm: $175.00; 1pm – 4pm: $175.00

Please return this form along with a check for the above session(s) to:
MAIL TO: Camp Coordinator - Cindy Quan
San Francisco Viking Soccer Club
2521 Judah St.
San Francisco, CA 94122
For more information or an application call Cindy Quan 753-3111, Mailbox #2
SAN FRANCISCO VIKING SOCCER CLUB * 2521 JUDAH ST., S.F., CA 94122, (415) 753-3111