Upper Sandusky

Lady Rams Soccer Camp

June 10-13, 2019
Upper Sandusky H.S. Soccer Fields
*In the event of a weather cancellation, camp will be rescheduled for Fri. June 14*

Grades 1-4 5:00 pm-6:30 pm

Grades 5-8 6:30 pm-8:00 pm
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Detach & return bottom in sealed envelope

Student Name: Upcoming Grade:

Parent / Guardian Name(s):

P/G’s Emergency Phone:

Cost: $40 — Includes T-shirt & Soccer ball

Make checks payable to: USHS Girls Soccer

Shirt Size: CHILD: S M L ADULT: S M L

(Circle One)

• Registration deadline to guarantee a T-shirt & soccer ball is Friday May 17th, but
campers may register up to the day of the camp.
• Turn in camp form to your Upper Sandusky school OR mail / drop off to USHS
with c/o: Patrick Massara at 800 N. Sandusky Ave. Upper Sandusky, OH 43351
I hereby authorize the Lady Rams Soccer Staff to act according to its best judgment
in case of an emergency requiring attention and I waive and release the camp from
any liability for injuries or illness while at camp.

Parent/Guardian Signature: Date:

Also complete emergency medical information on back of form

For more information, contact PATRICK MASSARA (419-348-0726) or the USHS
office (419-294-2308).
 2019 Lady Rams Soccer Camp
Remind Messages

These shall be used for communication purposes from the camp staff (weather, etc.).

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Detach & return bottom in a sealed envelope
EMERGENCY MEDICAL AUTHORIZATION FORM
STUDENT’S NAME:
STUDENT’S ADDRESS:
Street City State Zip
STUDENT’S PHONE:
19-20 GRADE: BIRTHDATE: SOC. SECURITY #:
PURPOSE: To enable parents/guardians to authorize the provision of emergency treatment for children who become ill or
injured while under camp authority, when parents or guardians cannot be reached.

RESIDENTIAL PARENT(S) OR GUARDIAN(S): In order of preference to contact

P/G #1: PHONE:
P/G #2: PHONE:
Emergency Contact #3: PHONE:
If your child has any particular health condition, previous injuries or major illnesses, allergies, physical impairments,
or medications being taken to which a physician should be alerted, please indicate on an attached paper.
I/we will not hold the Upper Sandusky School System, its employees, or any part of its departments responsible for
any bills resulting from injury to the named athlete.
TYPE OF HEALTH/MEDICAL INSURANCE:
POLICY GROUP NUMBER: POLICY HOLDER’S NAME:
I hereby give consent for the following medical care providers and local hospital to be called:
PHYSICIAN: PHONE:
DENTIST: PHONE:
MEDICAL SPECIALIST PHONE:
PREFERRED HOSPITAL: PHONE:
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the
administration of any treatment deemed necessary by above named doctors, or in the event the designated preferred
practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital
reasonably accessible. Permission is also granted to Upper Sandusky Schools’ staff members and/or local rescue teams to
provide the needed emergency treatment to the student prior to admission to the medical facilities. This authorization does not
cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for
such surgery, are obtained prior to the performance of such surgery.
SIGNATURE OF PARENT/GUARDIAN: DATE: