2009 OC Soccer Camp

December 19 - 21

CAMP REGISTRATION (Please use a separate registration form for each camper)
CAMPER’S FULL NAME ____________________________________________
DATE OF REGISTRATION_______________

RESIDENCE ADDRESS_______________________________CITY_________________STATE_________ZIP____________

DATE F BIRTH______________________20________AGE AT LAST BIRTH_____________MALE_______FEMALE_______

SCHOOL______________________________________________ GRADE _______________________________________

SHIRT SIZE YS YM YL SML

TELEPHONE NUMBER AT HOME _______________________________

E-MAIL ADDRESS__________________________________________

PARENT (1)
EMERGENCY CONTACT INFORMATION: OFFICE_________________________CELL PHONE__________________________
FULL NAME________________________________________________
RESIDENCE ADDRESS_______________________________CITY_________________STATE_________ZIP____________

PARENT (2)
EMERGENCY CONTACT INFORMATION: OFFICE_________________________CELL PHONE__________________________
FULL NAME________________________________________________
RESIDENCE ADDRESS_______________________________CITY_________________STATE_________ZIP____________

Where did you here about us? _________________________________________________________________________

Make checks payable to “OC Soccer Camp”

Mail to:
Mike Chilcott
665 South Rockridge
Anaheim Hills, CA 92807

If you have any questions, feel free to contact:

Mike Chilcott
310-925-8838
wmchilcott@aol.com

or

Gary Kleiban
gary.kleiban@gmail.com