Soccer Camp for 2024 is the week of June 10
(Monday – Thursday in the evenings)
4-6 years old 6pm-7:15 – 7-14 years old 6pm-8pm
McConnell Sports Complex Washington
WHS Soccer Coach Jim Kozuch & WHS soccer players
Ages 4-14
Fundraiser for the WHS teams.
The cost is $50
Each Camper will get a T-Shirt (paid & registered by May 24th)
Refreshments will be provided each night
We recommend parents to send water bottle with the camper
each night to have at the field with them
Campers wear shin guards and bring a soccer ball to camp
Please write the camper’s name on bottles & the soccer balls
Thursday night is watermelon night
Campers are divided by age at Camp
Fun games, agility, shooting and ball control skills.
A good way for a beginning player to learn and have fun
Experienced players get to sharpen their skills

  REGISTRATION

Soccer Camp Registration - Optimist Club of Washington

Registration for Optimist Club of Washington Soccer Camp. Monday - Thursday Evening Starting June 10, 2024. The camp is a fundraiser for Washington High School Soccer team for ages 4 - 14 years old.

"*" indicates required fields

Camper Name*

First Last

Camper Date of Birth*

MM slash DD slash YYYY

Please enter the camper's age as of June 10*

Please enter a number from 4 to 14.

Camper Shirt Size*

Youth X-Small (size 2-4)

Youth Small (size 4-6)

Youth Medium (size 8-10)

Youth Large (12-14)

Adult Small

Adult Medium

Adult Large

Adult x-Large

Camper Medical information or Allergies

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contact Name & Phone Number*

Camper Home Phone Number

Parent 1 Name*

First Last

Parent 1 Phone Number*

Parent 1 Email*

Parent 2 Name

First Last

Parent 2 Phone number

Parent 2 Email

Additional Comments

Medical Release Agreement*

I agree to the Medical Release

Waiver from Registration System. Optimist Club Of Washington Soccer Camp.
Medical Release and Liability Release and Waiver PLEASE READ ENTIRE TEXT-

I, the parent or guardian of participant a minor, hereby consent to their participation in the Optimist Club Soccer Camp. I further agree to release and save harmless the City of Washington and the Optimist Club of Washington, its officers, employees, agents, and attorneys from any and all liability or expenses arising out of any incident involving, or on account of any injury to the above named minor in connection with such program. I hereby give permission to the Optimist Club and coaches to authorize a physician at a local hospital to secure proper treatment for my our child as named above. Treatment Minor As the parent or legal guardian of the registering player, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. Care may be given under whatever conditions are necessary to preserve life, limb, or well being of my dependent. I have noted in comments any special medical needs or concerns. I also give permission for the use of photos of participant for promotion or social media posting.
CITY OF WASHINGTON and OPTIMIST CLUB OF WASHINGTON
WAIVER, RELEASE, INDEMNIFICATION AGREEMENT, AND COVENANT NOT TO SUE FOR MINOR BY ADULT

Consent*

I agree to the Liability Release for the City of Washington and Optimist Club

NOTICE: THIS IS A LEGALLY BINDING AGREEMENT. Please read this document carefully and in its entirety. By signing this Agreement, you give up your right and the named minor's right to bring a court action to recover compensation or obtain any other remedy for any personal injury, illness, or property damage however caused arising out of the named minor's participation in the Activity described below, now or any time in the future.

1. I recognize and am aware that the below minor’s permission to be on City premises and/or City maintained premises and/or to participate in a recreational league, program, or other activity ("Activity") will not be exclusive, but will be shared with others, is inherently dangerous, and could result in physical and/or mental injury, including death. I acknowledge that participation in said Activity includes possible exposure to and illness from infectious and communicable diseases including but not limited to MRSA, influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist and cannot be eliminated. I knowingly and freely undertake and assume all such risks, responsibility and dangers, both known and unknown, associated with the same, even if arising from the negligence of the Releasees or others, and assume full responsibility for the below minor's participation in the Activity.

2. I and the below minor willingly agree to comply with the stated and customary terms and conditions for participation, including but not limited to protections against infectious diseases. If, however, I or the below minor observe any unusual or significant hazard during our participation, I and the below minor will remove ourselves from participation and bring such to the attention of the nearest official immediately.

3. The below minor is in proper physical condition and has sufficient knowledge, skill, and training, as the case may be, to participate in said Activity.

In consideration for the below minor being allowed to be on City premises and/or City maintained premises and/or to participate in said Activity and other good and valuable consideration, the receipt and legal sufficiency of which are hereby acknowledged, I, the undersigned parent, guardian, or custodian of the below minor, for himself/herself and on behalf of said minor, do, for myself, my heirs, executors, personal agents, personal representatives, administrators, successors, assigns, and next of kin, hereby unconditionally waive, release, hold harmless, and will indemnify, acquit and forever discharge ("Release") the Optimist Club of Washington, it’s members and officers and the City of Washington its present and former employees and elected officials, in both their individual and official capacities, agents, personal representatives, attorneys, insurers, family members, heirs, successors, and assigns, and each of them, respectively, ("Releasees") of, from and for all and any manner of action or actions, cause and causes of action, claims, demands, costs, loss of services, expenses, attorney’s fees, compensation and all consequential, compensatory, general, special, and/or punitive damages or liabilities, ("Claims") known or unknown, whether arising from the negligence of Releasees or otherwise, to the fullest extent permitted by law, which may result directly or indirectly or in any way be related to or growing out of the below minor’s coming to, being on, or departing City premises and/or City maintained premises and/or participating in said Activity.

The foregoing Release shall include any and all negligence made or brought by the below minor or by anyone on behalf of said minor as a result of said minor’s participation in the Activity. In addition, I, for myself and on behalf of said minor, further agree not to sue any of the aforementioned parties as a result of any injury, paralysis, or death that said minor suffers in connection with the minor’s participation in the Activity.

The foregoing Release shall include any Claim arising from or related to any and all illnesses and communicable diseases, including COVID-19.

This Waiver, Release, and Indemnification Agreement for Minor by Adult ("Agreement") has been read by me and I fully understand its contents and terms. I understand that I have given up substantial rights by signing this Agreement and I sign it freely and voluntarily without any inducement. I also certify that I have read and explained the provisions of this Agreement to the below minor, including the risks of presence and participation and the below minor's personal responsibilities for adhering to the rules and regulations, including but not limited to protections against communicable diseases. Furthermore, the below minor understands and accepts these risks and responsibilities. This Agreement shall be binding as to the below minor as well as on me, my heirs, executors, personal agents, personal representatives, administrators, successors, assigns and next of kin.

CITY OF WASHINGTON and Optimist Club of Washington
WAIVER, RELEASE, INDEMNIFICATION AGREEMENT, AND COVENANT NOT TO SUE BY ADULT

NOTICE: THIS IS A LEGALLY BINDING AGREEMENT. Please read this document carefully and in its entirety. By signing this Agreement, you give up your right to bring a court action to recover compensation or obtain any other remedy for any personal injury, illness, or property damage however caused arising out of your participation in the Activity described below, now or any time in the future.

1. I recognize and am aware that my permission to be on City premises and/or City maintained premises and/or to participate in a recreational league, program, or other activity ("Activity") will not be exclusive, but will be shared with others, is inherently dangerous, and could result in physical and/or mental injury, including death. I acknowledge that participation in said Activity includes possible exposure to and illness from infectious and communicable diseases including but not limited to MRSA, influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist and cannot be eliminated. I knowingly and freely undertake and assume all such risks, responsibility and dangers, both known and unknown, associated with the same, even if arising from the negligence of the Releasees or others, and assume full responsibility for my participation in the Activity.

2. I willingly agree to comply with the stated and customary terms and conditions for participation, including but not limited to protections against infectious diseases. If, however, I observe any unusual or significant hazard during my participation, I will remove myself from participation and bring such to the attention of the nearest official immediately.

3. I am in proper physical condition and have sufficient knowledge, skill, and training, as the case may be, to participate in said Activity.

In consideration of being allowed to be on City premises and/or City maintained premises and/or to participate in said Activity and other good and valuable consideration, the receipt and legal sufficiency of which are hereby acknowledged, I do, for myself, my heirs, executors, personal agents, personal representatives, administrators, successors, assigns, and next of kin, hereby unconditionally waive, release, hold harmless, and will indemnify, acquit and forever discharge ("Release") the Optimist Club of Washington (Officers & Members) and the City of Washington, its present and former employees and elected officials, in both their individual and official capacities, agents, personal representatives, attorneys, insurers, family members, heirs, successors, and assigns, and each of them, respectively, ("Releasees") of, from and for all and any manner of action or actions, cause and causes of action, claims, demands, costs, loss of services, expenses, attorney’s fees, compensation and all consequential, compensatory, general, special, and/or punitive damages or liabilities, ("Claims") known or unknown, whether arising from the negligence of Releasees or otherwise, to the fullest extent permitted by law, which may result directly or indirectly or in any way be related to or growing out of my coming to, being on, or departing City premises and/or City maintained premises and/or participating in said Activity.

The foregoing Release shall include any and all negligence made or brought by me or by anyone on my behalf as a result of my participation in the Activity. In addition, I further agree not to sue any of the aforementioned parties as a result of any injury, paralysis, or death that I suffer in connection with my participation in the Activity.

The foregoing Release shall include any Claim arising from or related to any and all illnesses and communicable diseases, including COVID-19.

This Waiver, Release, and Indemnification Agreement by Adult ("Agreement") has been read by me and I fully understand its contents and terms. I understand that I have given up substantial rights by signing this Agreement and sign it freely and voluntarily without any inducement. This Agreement shall be binding on me, my heirs, executors, personal agents, personal representatives, administrators, successors, assigns, and next of kin.

By Agreeing to this waiver and Release you are submitting an electronic signature for you and your player(s).

Payment

Payment Type*

Cash

Check

Credit/Debit Card

Cost Per Player is $50.00 You may remit by credit/debit, cash or check.

Cash Payment

Do NOT send cash payments by mail. Information will be provided on the website for a date/time and location to provide payments in cash. For further information you can contact club board members through optimistwash@gmail.com. REMEMBER to click the Submit button below to complete the registration form, however, REGISTRATION IS NOT COMPLETE UNTIL THE PAYMENT HAS BEEN RECEIVED.

Pay by Check

Payments by check can be mailed to Optimist Club of Washington, P.O. Box 1174, Washington, NC 27889. REMEMBER to click the Submit button below to complete the registration form however, REGISTRATION IS NOT COMPLETE UNTIL THE PAYMENT HAS BEEN RECEIVED.

Credit/Debit Card Payment

Soccer Camp Registration

Price:

Cardholder Email*

Cardholder Name*

First Last

Cardholder Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Credit/Debit Card

Enter name as it appears on card

Card Details

Comments

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Any questions, email optimist club at optimistwash@gmail.com