ࡱ> CEBq` bjbjqPqP **::]ZZZZZZZn2228j~nl"2!!!!!!!$#h&"Z"ZZ&"dZZ!!k!ZZ! PGs2(!!<"0l"!,&&!&Z! *sQ""Xl"nnn2nnn2nnnZZZZZZ 2008 Revolution Academy Application and Release Form Participant(s) Name(s):________________________________________________________________ Age & Grade at Academy Time: _______________ Soc. Sec.#:_______________________ Parent/Guardian Name:___________________________________________ Email: _________________________________________________________ Address:______________________________________________________________________ City: ________________________State: ____ Zip: ______ Home Phone: (________)_________________________________________ Work Phone: (_______)_______________________________________ Emergency Contact: ____________________________ Phone: (________)______________________ Are you a Center Circle Member: ( Yes ( No Please check the session(s) you wish to attend: Player Development Program (9am-12pm, 10am-1pm or 5pm-8pm) ($175) ___ Cranston (4/14-4/17 9-12) ___ Londonderry, NH (6/17-6/20) ___ Westwood, MA (7/7-7/10 5-8) ____ Sandwich (7/7-7/10 9-12) ___ Cranston (7/21-7/24 5-8) ___ Braintree, MA (7/14-7/17 9-12) ___ Tewksbury (8/11-8/14 5-8) ___ Norwell (7/21-7/24 9-12) ___ Swansea-Somerset(8/4-8/7 5-8) ___ Beverly (7/14-7/17 5-8) ___ Norwell (8/18-8/21 9-12) ___ Foxborough (8/4-8/7 9-12) ___ Smithfield, RI (8/25- 8/28 4.30-7.30) ___ Northboro (7/28-7/31 9-12) ___ Old Orchard Beach (6/23-6/26 10-1pm) ___ West Bridgewater (7/14-7/17 9-12) ___ Westford (8/11-8/14 9-12) ___ Waterville (6/23-6/26 5-8) * Player Development Program is for Boys and Girls ages 7-16. Please Circle Shirt Size: Youth: S M L Adult: S M L Participants Medical Information Please attach pediatricians medical forms (including medical history, evidence of physical within last 24 months; age and grade appropriate vaccinations; verification that child is fit to participate in sports) Insurance Provider:__________________________________________________________ Policy Number: ____________________________________ Primary Care Provider:_______________________________________________________ Physicians Phone:__________________________________ Childs Allergies/Medical Conditions:_____________________________________________________________________________________________ Authorization to administer medication at Revolution Academy: I hereby authorize the Revolution Academy to administer to my child the following medications: ____________________________________________________________________________________________________________________________ Please deliver prescription medicine in original bottle to on-site health supervisor at check-in. I hereby allow my child to self-administer the following medications: ____________________________________________________________________ In the event of illness or injury, I grant the Revolution Academy the right to take appropriate action for my childs health and safety and to obtain any necessary medical assistance. I will be fully responsible for all medical expenses incurred by my child while attending the program. I certify that my child is in good health and is able to participate in physical activities, including soccer. I, the undersigned for ourselves, our heirs, executors and administrators waive, release, and forever discharge the Revolution Academy, New England Revolution, NPS, LLC, Kraft Soccer LLC and their affiliates, staff and assigns of and from all rights and claims for damages, injury or loss to person or property which may be sustained during participation in camp activities or while at camp. I understand that lost equipment and personal belongings are not the responsibility of the Revolution Academy. I give permission for the Revolution Academy and New England Revolution to use my childs image in future advertising and promotional materials. I have read and freely signed this agreement, which shall take effect as a sealed instrument. Parent/Guardian Signature:_________________________________________________________________________________- Date:_____________________ Please send check payable to the New England Revolution to: 2008 Revolution Academy c/o Ben Rawitz One Patriot Place Foxborough, MA 02035-1388 Or pay by (circle one): Mastercard Visa AMEX Credit Card #:_____________________________________________________________________Expiration Date:____________________________________ Cardholder Name____________________________________________________________________________________________________________________ Cardholder Signature:_________________________________________________________________________________________________________________ Please Note: Certain restrictions apply to the Academy enrollment. Be sure to read the full description of each to see which is the right Academy program for you. REFUND POLICY: 50% reimbursement of the balance if cancelled up to 7 days prior to the Academy program. OFFICE USE ONLY: Deposit_____Balance______Paid in full____     For more information or to register on-line log onto www.revolutionsoccer.net.   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