Ascoli Soccer Camp Registration Please fill out the form below to register for Ascoli Soccer Camp. Age Group   Boys 8-12 years of ageBoys 13-19 years of age Player Information First Name      Last Name     Gender - Select - Male Female   Birthdate - Select - January February March April May June July August September October November December (Month)   - Select - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 (Day)   (Year - 4 digit)     Address   City      State   - Select - Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Lousiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Other Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming   Choose 'Other' if outside US! Zip      Country   AALAND ISLANDS AFGHANISTAN ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOWINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO, Democratic Republic of (was Zaire) CONGO, Republic of COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA (local name: Hrvatska) CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HEARD AND MC DONALD ISLANDS HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN (ISLAMIC REPUBLIC OF) IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, Occupied PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA AND MONTENEGRO SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN ISLANDS SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VATICAN CITY STATE (HOLY SEE) VENEZUELA VIET NAM VIRGIN ISLANDS (BRITISH) VIRGIN ISLANDS (U.S.) WALLIS AND FUTUNA ISLANDS WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE Phone      Type   Cell Home Work Email     T-shirt size   Youth SmallYouth MediumYouth Large Adult SmallAdult MediumAdult Large   Note to Camp Directors Parent Information Parent #1 First Name      Last Name     Email     Home Phone      Work Phone   Cell Phone Parent #2 First Name    Last Name   Email   Home Phone    Work Phone   Cell Phone Medical Information Medical insurance company Medical insurance policy # List any medical concerns (allergies, asthma, e.g.) Doctor's name Doctor's phone number Emergency Information Emergency Contact Person #1 Name   Phone   Emergency Contact Person #2 Name Phone Release And Agreement Release and agreement: I, the parent of the player named hereon acknowledge that participation in the sport of soccer, as in any sport, may result in injury. I hereby release Sports in USA, Inc., its Agents, Coaches, and staff from all liability or responsibility for any claim, damage, or legal action on behalf of the player or the player’s parents, heirs, or personal representatives arising from any injury the player may sustain while participating in soccer or related activities. I hereby authorize the staff of the Sports in USA, Inc. to act for me according to their best judgment in any emergency situation requiring medical attention. I give my consent for emergency medical care prescribed by a licensed doctor of medicine or dentistry. I, also, understand Sports in USA, Inc. retains any right to use in documenting the activities of Empoli Soccer Camp, for educational and promotional purposes, photographs or video of campers taken at camp. Sports in USA will NOT be responsible if it is unable to commence, continue or completely perform its obligations hereunder by reason of force majeure, fire, flood, hurricane, Tropical Storm, typhoon, aircraft damage, war, state of national emergency, local or USA Government action or any cause whatsoever (whether or not of similar nature to the forgoing) which is not within its control. I agree to the above release and agreement. RESPONSABILITY: The organization is responsible for the taking place of the activities of the camp chosen, under the condition that the activities are executed as directed by the camp instructors. The Ascoli Soccer Academy, during the period of the selected camp will not be in any way responsible for any damage; physical or not. Every participant has to follow all the rules of good education and respect of others. IMPORTANT NOTE: Submission of an application and payment does not guarantee acceptance to the camp. Upon acceptance, a confirmation will be forwarded to you. If not accepted, your payment will be reimbursed in full. CANCELLATION AND REFUNDS: In case of cancellation, the player or is tutor needs to send a Fax or letter before June 10th 2009 to Mare Events, Corp. 4265 Conway Place Crl, Orlando, FL 32812 or Fax: 407-251-6368. In the letter or fax it needs to be stated the decision to cancel, the first and last name of the player and the period previously selected. The Ascoli Soccer Academy and Mare Events will refund the amount of registration minus a $300 in penalty. All the cancellations received after June 10 2009 will receive no refund. Camp Dates and Payment   $1,050.00 Ascoli Soccer Camp for ONE Week $2,100.00 Ascoli Soccer Camp for TWO Weeks $2,870.00 Ascoli Soccer Camp for THREE Weeks 1st Week: June 29- July 5 2009 2nd Week: July 6- July 12 2009 3rd Week: July 13- July 19 2009 Please indicate which week(s) you want to join the camp in the "Note to Camp Directors" under the Player Information section. For instance, if you choose TWO Weeks, then you just type in "I want to participate in the 1st and 3rd week" in the Note to Camp Directors box. We accept the following payment options: