Select Camp: Select One Residential Camp Day Camp (Full) Day Camp (Half) Goalkeeping Camp Elite College Prep Camp Elite College Prep Goalie Camp Fut Sol Camp                                                                               Week: Select One June 7 - 12, 2009 June 14 - 19, 2009 June 21 - 26, 2009 June 28 - July 3, 2009 July 5 - 10, 2009 July 12 - 17, 2009 July 19 - 24, 2009 July 26 - 31, 2009 August 2 - 7, 2009

Parent/ Guardian Information:

Name:     EMail:

Address:

City:      State:      Zip:     Country:

Home Phone: Cell Phone: Work Phone: Fax Number:

Emergency Contact/ Medical Information:

Name:     Phone:

Family Doctor:     Phone:

Camper Allergies/ Known Conditions:

Last Tetanus:     Family Health Insurance Company: Policy Number:

Camper Information:

Name:     Age:     Gender:     Position: Select One Forward Midfielder Defender

Uniform Shorts Size: Select One YS YM YL AS AM AL AXL (Short size does not apply to day camps)    Uniform Shirt Size: Select One YS YM YL AS AM AL AXL

I would like my roommate(s) to be* -

We will make every effort to fulfill roommate requests.  Please separate multiple names with a comma.

Payment Method:

Options: Select Payment Options Visa MasterCard Sending Check           Payment Amount: 
*Please make check payable to: Cocoa Expo Sports Center Inc. Soccer Camps

Credit Card Number:     Expiration Date:     Name on Card:

Your Application is not considered official until your Application Fee is received by Cocoa Expo,
I hereby authorize Cocoa Expo Sports Center to charge my credit card that I have listed above. I understand that once my application is submitted there will be no refunds issued. The Cocoa Expo Sports Center will not be responsible for any expense incurred by any participants due to particpants dismissal due to the breaking of the camp code of conduct.
Please type name here indicating that you have read the above conditions

Even if you do not pay with a credit card, you must read the above conditions.