SPRING BREAK CAMP
Grades K-thru-5

Drills & Small-sided Scrimmages at Takoma Park Middle field & gym
Director – Adrian Baez, Blair varsity coach

Have Fun! Learn Soccer!

Half-day program (9 a.m. - Noon)
Monday – March 24th - thru - Friday - March 28th


Limit of 60 players. First-come, first-served. You will be sent a letter with a full list of information. For questions contact Howard Kohn (kohn@erols.com).


Player’s Name   Birth:    Grade    Gender

Names of Parents

Address

Phone (home) (work)

E-mail address (important!)

Name & Number of Emergency Contact (during program week):

Medical Needs or Other Special Information:

I hereby give my child permission to participate in this soccer program. I understand that no accident insurance is provided, and I agree that I will not hold TPNYS or the Takoma Park Recreation Department responsible for any injury sustained while participating in this program.

Signature of Parent or Guardian ______________________________________________


Fee: $75 (Write checks to Takoma Park Soccer or TPNYS) Mail to: TPNYS, 16 Jefferson Ave., Takoma Park, Md. 20912


NOTE: We need an original signature on the form.