Creighton Soccer Academy

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Creighton Soccer Academy Application

Applicant's Information
First Name:	*
Last Name:	*
Date of Birth:	*
Position:	*
Address:	*

City:
State:
Zip:
Email:	*
Which Camp:	*
Overnight or Commute:	Overnight Commute *
Do you need a shuttle from the airport:	Yes No *

Emergency Contact Information
Mother's Name:	*
Mother's Home Phone:
Mother's Work Phone:
Mother's Cell Phone:

Father's Name:	*
Father's Home Phone:
Father's Work Phone:
Father's Cell Phone:

Health Information
Age at Camp:	*
Medications:
Allergic Reactions:
Illnesses or Injuries:
Last Tetanus Shot:	*

I hereby certify that the Creighton Soccer Academy staff has full and unconditional authority to proceed with diagnosis and treatment as judgement indicates for injuries during the camp. The Creighton Soccer Academy and Creighton University shall not be held responsible for any consequence resulting from such injuries. I declare that I am the parent/guardian of the above-named minor.

Agree Disagree *


Insurance Information
Insurance Company:	*
Insurance Agent:	*
Policy Holder:	*
Policy Number:	*
Other Information
Roommate Request (At most 25 characters):
Coming With a Team (At most 30 characters):
Friends:

Payment Option:	Now By Check *

Buy a Creighton soccer ball online
or you may mail us your payment of $35:

Pay for the shuttle service online buy clicking below
or you may mail us your payment of $20: