Please print, fill out, enclose a check for $85 and mail this form to:
Emil Dragicevic Pro
Soccer Camp
P.O. Box 3341
St. Louis, MO 63022
Camper's Name:______________________________________ Phone (H):_______________ (W):_______________
Address: ____________________ City:____________________ St:________ Zip:_______
Camper's Age:_____Birthdate: ___/___/___ Male/Female:____ T-Shirt Size:____ (Youth S, M, L, XL) Bring Your own soccer ball.
Skill Level: [ ] Beginner [ ] School Team [ ] Select Team, Team name:________________________
If you have any questions call Emil at 636-227-8796 or check www.EmilDragicevic.com for more information
Please put a check next to the camp you would like to attend!
2005 SOCCER CAMPS
| $85 | June 6 - 10, 6 - 8 PM | YMCA-Wildwood 2641 Highway 109, Wildwood 63040 | |
| $85 | June 13 - 17, 9 - 11 AM | Wildwood Middle School 17401 Manchester Rd. Wildwood 63038 | |
| $85 | June 13 - 17, 6 - 8 PM | Wildwood Middle School 17401 Manchester Rd. Wildwood 63038 | |
| $85 | June 20 - 24, 6 - 8 PM | New City School 5209 Waterman, St. Louis 63108 | |
| $85 | July 18 - 22, 9 -11 AM | Chesterfield Elementery 17700 Wild Horse Creek Rd. Wildwood 63005 | |
| $85 | July 25 - 29, 9 -11 AM | Selvidge Middle School 1235 New Ballwin Rd. Ballwin 63021 | |
| $85 | July 25 - 29, 6 - 8 PM | St. Joseph - Manchester 567 St. Joseph Ln. St. Louis 63021 | |
| $85 | August 1-5, 9 - 11 AM | Berra Park St. Louis on the Hill | |
| $85 | August 1-5, 6 - 8 PM | Parkway West High School 14653 Clayton Rd. Ballwin | |
| . | $220 | August 8-12, 9 AM- 3 PM | New City School 5209 Waterman, St. Louis 63108 |
| . | $85 | August 15-19, 9 - 11 AM | Truman Elementary 12225 Eddie & Park Rd. St. Louis 63127 |
| . | $85 | August 15 - 19, 6 - 8 PM | Truman Elementary 12225 Eddie & Park Rd. St. Louis 63127 |
I, ________________________ hereby authorize the Emil Dragicevic Pro Soccer Camp to act for me according to their best judgment for ___________________ in any emergency requiring medical attention and hereby waive and release the Emil Dragicevic Pro Soccer Camp from liability for injury or illness incurred while at the camp or traveling to and from the camp. I verify that the above named applicant is physically able to participate in the activities of the camp. I waive and forever discharge the Emil Dragicevic Pro Soccer Camp from any and all rights and claims for damages to persons or property while at the camp.
___________________________________
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( signature of parent or legal guardian )
( date )