2015 Residential Soccer Camps
Camp and Instructional Information Welcome and congratulations on taking a major step in the right direction to improving yourself on and off the field. We are excited to have you at our facility and anticipate a very successful camp. Please review the attached camp details along with what to bring. Part of success, is perfect planning for the unexpected. Therefore, we require the following forms: 1. 2. 3. 4. 5. 6. 7. Registration Terms and Conditions Consent for Medical Treatment Authorization Medical Insurance Information Immunization Record Indemnification, Release, Waiver of Liability and Assumption of Risk Agreement Physician’s Report a. ECG (prepared by your physician) b. Echo Cardiogram (prepared by your physician) c. Letter of Clearance (prepared by your cardiologist) 8. Passport size headshot photo of player. Please email all forms to [email protected] or you can mail all the forms to: Grande Sports World Att: Grande Sports Academy 12684 West Gila Bend Highway Casa Grande, AZ 85193 Thank you, Miha Kline Miha Kline Director of Recruiting GRANDE SPORTS ACADEMY - Registration Form: Player’s Info: First Name_______________________________ Last Name______________________ Age:________ Position _________________Shirt Size (Circle one) S M L XL XXL Address___________________________________ City__________________________ State______ Zip________ Home Phone:_____________ Birthdate:_____________________ Club/Team______________________________ Club/Team______________________________________________________________ Mother/Guardian Cell #__________________________ Work #:__________________ Email _________________________________________________________________ Father/Guardian Cell #:_________________________ Work #: ___________________ #:Email__________________ Roommate Request: ___________________________ How did you hear about the camps?____________ Camp Dates One Week Program March 29 – April 4, 2015 May 31 – June 6, 2015 June 7 – June 13, 2015 June 14 – June 20, 2015 June 21 – June 27, 2015 June 28 – July 4, 2015 July 5 – July 11, 2015 July 12 – July 18, 2015 July 19 – July 25, 2015 Two Week Program May 31 – June 13, 2015 June 14 – June 27, 2015 June 28 – July 11, 2015 July 12 – July 25, 2015 Three Week Program June 7 – June 27, 2015 July 5 – July 25, 2015 Four Week Program June 28 – July 25, 2015 May 31 – June 27, 2015 Six Week Program June 7 – July 18, 2015 Eight Week Program May 31 – July 25, 2015 Striker & GK Camp - $495 ($200 as add-on) June 19 –June 21, 2015 July 17 – July 19, 2015 Camp Pricing: One Week Program - $995 Two Week Program - $1,940 Three Week Program - $2,835 Four Week Program - $3,730 Six Week Program - $5,520 Eight Week Program -$7,310 Camp pricing includes all meals, accommodations, training, sales tax, service fee and t-shirt. Payment Options: Credit Card Payment – Attach Confirmation to Application Visa Mastercard CC #: _________________________________ Expiration Date: __________________ Security Code__________ Cardholder Name: ______________________________________________________________________ Cardholder Signature (required):____________________________________________________________ Check (payable to Grande Sports Academy) Amount Enclosed $__________________________ By signing and submitting this enrollment application to Grande Sports Academy, I affirm that I have read, submitted and accept all of the Grande Sports Academy forms as listed on the Camp and Informational page . Signature of Parent (or Guardian): __________________________________ Date: _______________Print Name: ______________________________________ GRANDE SPORTS ACADEMY Terms and Conditions Name of Child: ____________________________________________________________________ 1. Rules and Regulations: The child/student (“child”) and parent/guardian(s) (“Parents”) agree to abide by all of the rules and regulations established by Grande Sports World (“Camp”) including, without limitation, those relating to enrollment and withdrawal of child and visitation. 2. Dismissal of Child: The Camp reserves the right to dismiss, at its sole discretion, any Child whose condition, conduct, influence or behavior is deemed unsatisfactory, illegal or detrimental to the best interests of the Camp or other children/students or who violates camp rules and regulations, in which case no refunds will be made. 3. Late Arrival / Early Departure: No allowance or reduction will be made for late arrival or early departure of Child without the Camp Director’s (“Director”) consent prior to the start of camp. Grande Sports Academy can not guarantee a registration for child or children arriving after their scheduled date. There will be an adjustment made only if the Camper’s health requires an early departure. 4. No Shows: A confirmed child who fails to arrive on their scheduled date or cancels after cancellation date listed will be considered a no show and their entire registration will be cancelled. No refunds will be given. 5. Cancellations: Should registration become necessary to be cancelled, Grande Sports Academy must receive cancellation notification in writing. In the event of cancellation 0 to 30 days prior to event, liquidated damages in the amount of one hundred percent (100%) registration revenue will be due. In the event of cancellation 31 to 60 days prior to event, liquidated damages in the amount of ninety percent (90%) of the registration revenue will be due. Grande Sports Academy reserves the right to cancel the reservation or event at any time due to inclement weather, unsafe facility conditions and/or to avoid damage to the facility. 6. Belongings: The Camp is not responsible for articles of clothing or personal belongings lost or damaged by fire, theft, laundry, etc. Camp is not responsible for any items which includes and not limited to electronic devices, laptops, cell phones, iPods, jewelry, medical or dental devices. 7. Communications: Camp is not responsible for communications by employees past or present or child past or present, to children or parents/guardians through mail, online, email internet, texting or social networking sites. 8. Damages: Parents/Guardians assume full responsibility for any damages to any part of Grande Sports World, Grande Sports Academy or Francisco Grande Hotel & Golf Resort premise by child. Damage charges will be applied to credit card. 9. Real Salt Lake Involvement: Real Salt Lake is an affiliate of Grande Sports Academy and not a partner, investor, director, employee, employer or owner of Grande Sports World, Grande Sports Academy or Francisco Grande Hotel & Golf Resort. Child, Parent, Guardian agrees to hold Real Salt Lake harmless from any and all liability, damages, costs and expenses in connection with any and all claims, actions or causes of actions for injury, death or property damage arising from or out of the use and occupancy of the facility. 10. Force Majeure: No damages shall be due for a failure of performance occurring due to Acts of God, war, terrorist act, government regulation, riots, disaster, or strikes, any one of which make performance impossible. Grande Sports World or Francisco Grande Hotel & Golf Resort shall have no liability for power disruptions of any kind. Signature of Parent or Guardian: _________________________ Date: ___________ Print Name: ____________________________________________________________ Signature of Child (if age 18) : ____________________________ Date: ___________ GRANDE SPORTS ACADEMY Consent for Medical Treatment This is to certify that the administrative staff of Grande Sports Academy is being given authority by me, _______________________________________of____________________________________________ Print Name of Parent or Guardian Print Name of Child Born on __________________________________ Child’s Birth Date (mm/dd/year) To act on my behalf for any medical care, treatment (including immunizations) and prescriptions reasonably necessary or medically advisable to maintain the life, health and well-being of my child. This includes but is not limited to: First Aid Treatment * Prevention and Care of Injuries * Follow-up Care Taking of over-the-counter prescriptions that are approved by a physician even when the child is not seen by a physician. The consent for treatment extends to the signing and completion of: 1. 2. 3. 4. 5. 6. 7. Legal authorization for treatment Consultations Emergency examinations Consent for hospitalization Anesthesia Dental Care Treatment or surgery that may be deemed necessary by appropriate medical personnel. This authorization is given in advance of any specific diagnosis, treatment or care required, but is given to provide authority and power to render care that is deemed advisable in the best judgment of a physician. The undersigned will furnish payment or insurance for any such payment, at his/her expense. Home Address:___________________________________ City:_________________________________ Country: ________________________________________ State: ________________ Zip: ___________ Home Phone: _________________________________ Mobile Phone:____________________________ (Please list Country Code, city/Area Code/Phone Number) Work Phone: __________________________________ Fax: ___________________________________ (Please list Country Code, city/Area Code/Phone Number) Email Address: _____________________________Emergency Contact:___________________________ List below any specific medical information, i.e., allergic reaction to certain drugs, medications that a physician should be aware of when treating your child: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Parent or Guardian Signature: _________________________ Date: ____ Note: Parent/Guardian is to provide a copy of their Driver’s License to be attached to the Consent to Medical Treatment form. GRANDE SPORTS ACADEMY Medical Insurance Information: _______________________________________of____________________________________________ Print Name of Child Print Name of Parent or Guardian In most instances, medical fees will be charged to your credit card. Medical providers typically do not use international insurances. PLEASE PROVIDE A COPY OF THE FRONT AND BACK OF MEDICAL CARD. Insurance Company: _________________________________________________________________ Name of Policyholder: ______________________________ Birthdate of Policyholder: ____________ Relationship to Insured: ____________________________Group Policy No: ____________________ Credit Card No: ____________________________________ Exp Date: _________________ Name of Cardholder: _____________________________Security Code:___________________ Signature of Cardholder: _______________________________________________________ Card Company: Visa _____ Master Card _____ American Express _____ Discover Card _____ Additional Requirements/Dehydration and Sunscreen: The students work outside in a hot climate and dehydration can occur quickly. Please instruct your child on the importance of adequate fluid consumption. Ice machines are located on site and water supplies are provided at each sport. Student should bring ample supply of sunscreen and should apply it several times a day. Medical Facilities: Grande Sports World is supported by the following local medical facilities: Casa Grande Regional Medical Center 1800 East Florence Blvd Casa Grande AZ 85122 Phone: (520) 381-6932 Emergency Room open 24 hours Casa Grande Urgent Care 1676 W McMurray Blvd Casa Grande AZ 85122 Phone: (520) 316-0688 Open from 9 AM to 9 PM every day including weekends NextCare Urgent Care 1729 N Trekell Rd Casa Grande AZ 85122 Phone: (520) 876-0800 Open from 8 AM to 8 PM Monday through Friday Saturday and Sunday 8 AM to 4 PM MBI Occupational Healthcare 177 West Cottonwood Lane, Suite 1 Casa Grande, AZ 85122 Phone: (520) 836-3800 GRANDE SPORTS ACADEMY Physician’s Report ~ IMMUNIZATION RECORD Name of Child: __________________________________________ Immunizations: Dates Received (MM/DD/YY): DPT (Diptheria, Tetanus, Pertussis) Or TD (Tetanus, Diptheria Or DPT-Hib (5 required): Td: Tetanus: _______________________________ _______________________________ _______________________________ _______________________________ Polio, OPV.IPV-41 dose required if 3rd given before age 4: _______________________________ MMR (Mumps, Measles, Rubella) 2 doses required: _______________________________ Hepatitis B (Series of 3 required): _______________________________ ___________________________________________________________________________ HIB 0-14 mo: 3-4 doses _______________________________ 14-49 mo: 1 dose _______________________________ ___________________________________________________________________________ Varicella (Chicken Pox) required unless documented history of disease: Vaccine: Vaccine: Disease: _____________ ____________ _______ ___________________________________________________________________________ Tuberculosis Test: Date Placed:___________________ Within the Past Year: _____________________ Positive:_____________________ Negative _______________________ Mmx __________________ Date Read: ____________ Omm: _________________________ Mn__________________________ ___________________________________________________________________________ Have you ever received the BCG Vaccine: Yes: ________ Date: _______________________ No: ________ Disease Unknown: ________ __________________________________________________________________________ 1. DPT/DPTaP5: 5 doses required. If the 4th primary dose is given on or after the 4th birthday, a 5th dose is not required. 2. Td: Students 11 years old are required to have vaccine if they have not had the booster vaccine in the past 5 years. 3. Polio: 4 doses required. If the 3rd dose in an all OPY or all IPV is given on or after the 4th birthday, a 4th dose is not required. 4. HIB: Required for childcare, and pre-school attendance only. 5. MMR: First dose valid if given on or after 1st birthday. Second dose valid if given at least 1 month after 1st dose. 6. Hepatitis B: Series of 3 vaccines given as follows: HBY #1; HBY #2: 1-2 months later; HBY #3: 4-6 months. 7. Varicella: Varicella vaccine is not required if there is documentation of having Varicella disease. Children 13 years of age and older should receive 2 doses given at least 4 weeks apart. Children less than 13 should receive 1 dose. 8. TB test: The TB questionnaire is due annually for all full-time students. Short-time students are not required to complete the TB questionnaire. If any of the questions are answered yes (and there is previous history of BCG vaccination) a Mantoux TB test is required. If there is history of previous BCG vaccination, a chest x-ray is required (only if you answered yes for a question). 9. BCG: Don’t worry if you have never received this vaccine. Many foreign countries give this vaccine to children. NOTE all students are required to have varicella, tetanus & MMR. Signature of Person Completing Vaccination Form: __________________________________________ Date: ______________________________________________________________________________ Print Name: _________________________________________________________________________ GRANDE SPORTS ACADEMY INDEMNIFICATION, RELEASE, WAIVER OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT Name:_______________________________________________________ In consideration of being allowed to participate in GRANDE SPORTS ACADEMY, and related events and activities the undersigned: 1. Acknowledges and fully understands that each participant will be engaging in physical activity that involve risk of serious injury, including permanent disability and death, and severe social and economic losses which might result not only from their own actions, inactions or negligence or from the use of equipment provided or supplied including, but not limited to: falls, contact with other participants, the effects of the weather, conditions of the premises, physical exertion, and the negligence of others. Further, that there may be other risks not known to us, or not reasonably foreseeable, such as disability or death. 2. Acknowledges and fully understands that the Participant may be exposed to contagious and potentially harmful or deadly disease. 3. Acknowledges and fully understands that Participant may be exposed to risks while traveling, attending events with large crowds, or related to receipt of any medical treatment. 4. Acknowledges and fully understands that Grande Sorts Academy has rules and standards of conduct and agrees to abide by those rules and standards. 5. Having read this Agreement and knowing these facts and in consideration of acceptance of Participant’s application to participate in a program at Grande Sports Academy, Participant for myself, representatives, and anyone entitled to act on my behalf or on behalf of my estate, release, waive, discharge and covenant not to sue or bring any action against Grande Sports World, Grande Sports Academy, Francisco Grande Hotel & Golf Resort, City of Casa Grande, Casa Grande Performance Institute, its affiliated companies, or any of their owners, members, directors, officers, employees, volunteers, sponsors, independent contractors or agents (hereafter “Releasees”), from demands, losses or damages on account of injury, including death or damage to property, caused or alleged to be caused in whole or part by the negligence of Releasees or otherwise. 6. Consents to all recording, photographing and filming of Participant and agree that Grande Sports Academy can use these recordings and images at any time and in any manner without payment to or additional consent of Participant or Parent/Guardian. 7. Agrees to defend, indemnify and hold Grande Sports Academy, Grande Sports World, Francisco Grande Hotel & Golf Resort, City of Casa Grande, Casa Grande Performance Institutes its affiliated companies and each of their owners, members, directors, officers, employees, volunteers, sponsors, independent contractors and agents, harmless from any and all loss, damage, claim for damage, liability, expense, or cost, including reasonable attorneys’ fees, which arise out of, or is any way connected with Participant’s enrollment in or presence at Grande Sports World. This indemnification provision shall apply to any and all acts or omissions, willful misconduct or negligent conduct, whether active or passive, on the part of Participant. This section shall survive the expiration or early termination of this Agreement. Name:______________________________________________________________ 8. Agrees that in the event that there is a dispute hereunder which the parties cannot resolve between themselves, the parties agree to settle the dispute by binding arbitration. The arbitration shall be held under the Commercial Arbitration Rules of the American Arbitration Association then in effect as modified herein. The matter in dispute shall be submitted to a single arbitrator, who shall be a lawyer in accordance with the Commercial Arbitration Rules of the American Arbitration Association then in effect as modified by this paragraph, mutually selected by the parties. In the event that the parties cannot agree upon the selection of an arbitrator within seven (7) days, then within three (3) days thereafter, the parties shall request the presiding judge of the Superior Court in and for the County of Pinal, State of Arizona, to appoint an independent arbitrator. In the event either party shall bring an action to enforce any term of this Agreement or to recover any damages for and on account of the breach of any term or condition in this Agreement, it is mutually agreed that the prevailing party in such action shall recover all costs including: all arbitration expenses, collection expenses, reasonable attorneys’ fees, necessary witness fees and costs to be determined by the arbitrator in such action. 9. The terms and conditions of this Agreement shall be governed by and interpreted in accordance with the laws of the State of Arizona. Any arbitration action brought by either party for the purpose of enforcing a right or rights provided for in this Agreement shall take place in Pinal County, State of Arizona. The parties hereby waive all provisions of law providing for a change of venue in such proceeding to any other county. 10. This Agreement and any attachments represent the entire agreement between Participant and GSW and supersede all prior negotiations, representations or agreements, either express or implied, written or oral. It is mutually understood and agreed that no alteration or variation of the terms and conditions of this Agreement shall be valid unless made in writing and signed by the parties hereto. Written and signed amendments shall automatically become part of the Agreement, and shall supersede any inconsistent provision therein; provided, however, that any apparent inconsistency shall be resolved, if possible, by construing the provisions as mutually complementary and supplementary. 11. If any part, term or provision of this Agreement shall be held illegal, unenforceable or in conflict with any law, the validity of the remaining portions and provisions hereof shall not be affected. 12. Participant and Parent/Guardian, on behalf of Participant’s heirs, next of kin, personal representatives, spouses, minor children, executors and assigns have read the above waiver and release, fully understand its terms including that they are giving up substantial rights, including the right to compensation for injury resulting from negligence of Grande Sports World, Grande Sports Academy, Francisco Grande Hotel & Golf Resort, City of Casa Grande, Casa Grande Performance Institutes its affiliated companies and each of their owners, members, directors, officers, employees, volunteers, sponsors, independent contractors and agents, harmless from any and all loss, damage, claim for damage, liability, expense, or cost, including reasonable attorneys’ fees, which arise out of, or is any way connected with Participant’s enrollment in or presence at GSW by signing this Agreement and acknowledge that they are signing the agreement freely and voluntarily, and intend their signatures to be a complete and unconditional release of all liability to the greatest extent allowed by law. Signature of Parent or Guardian: _________________________________Date: ___________ Signature of Participant (if age 18): _______________________________ Date: __________ Revised December, 2012 GRANDE SPORTS ACADEMY Physician’s Report Grande Sports Academy is dedicated to the health and safety of our athletes. For that reason, we have adopted the American Heart Association’s 12 Point Recommendations for Pre-participation screening of High School and College Athletes. If any of the following criteria are present, then all of the following items are required prior to participating at Grande Sports Academy: (1) ECG (2) Echo Cardiogram (3) Letter of Clearance from a Cardiologist. Results of these tests and a letter of clearance from the Cardiologist must be on file prior to the student’s arrival. Student’s Name: __________________________________________________________ Personal Health History: Comments: Exertional chest pain/discomfort: Syncope/near syncope: Excessive exertional and otherwise dyspnea/fatigue associated with exercise: Prior recognition of heart murmur: Elevated blood pressure: Yes No ___ ___ ___ ___ __________ __________ ___ ___ ___ ___ ___ ___ __________ __________ __________ Family Medical History: Comments: Premature death (sudden or otherwise) related to heart disease in relatives: Disability from heart disease in close relative younger than 50 years: Does the student have an ongoing illness, such as diabetes: Specific knowledge of hypertrophic or dilated Cardiomyopathy Ion Channelopathies such as long QT Syndrome, Marfan Syndrome, or clinically important Arrhythmias: Yes No ___ ___ __________ ___ ___ ___ ___ __________ __________ ___ ___ __________ ___ ___ ___ ___ ___ ___ ___ ___ __________ __________ __________ __________ Physical Examination: Heart Murmur: Aortic Coarctation noted on Femoral Pulse Exam: Physical Stigmata of Marfan Syndrome: Abnormal Brachial artery blood pressure: Date Date Notes: ___________________________________________________________________________ __________________ Remember, any “yes” answers need to result in (1) ECG (2) Echo Cardiagram (3) Letter of Clearance from a Cardiologist. Vision Screening Tests Date: Distance Acuity _________Right __________Left __________ With correction_______ Wears Glasses Yes: _______ No: ____ Right__________ Left __________ Without correction______Wears Contacts Yes: _______ No: _______ Physician’s Examination: Height: _______________ BP: ___________________ Weight: _______________ Pulse: _________________ Medications:__________________________________________________________________________ Reason Taken:________________________________________________________________________ Page 1 of 2 GRANDE SPORTS ACADEMY Physician’s Report Student’s Name: __________________________________________________________ Describe any variations from the norm. N = Normal Teeth _________ Eyes: ________ Ears: _________ Heart: _________ Scalp: _________ Extremities _________ Menses: _________ Chest X-Ray: _______ GJ System: _______ Vital Signs: _________ Ab = Abnormal Other: _________ Glands: ________ Skin: Abdomen: ________ _________ Abnormal Explained: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ NOTE: CXR must be done if student has had BCG or + TB This student is cleared to participate as follows: Unrestricted Clearance _______ Restricted _________ Clearance limitations are advised_____ Specify Limitations: ______________________________________________________________________________ ____________________________________________________________________________________ Additional information the examiner believes should be brought to the attention of Grande Sports World to enable the student to participate in athletics or to provide for the student’s well-being: ____________________________________________________________________________________ ___________________________________________________________________________________ ____________________________________________________________________________________ I understand that Grande Sports World programs may include vigorous physical activities and exertion, which can occur in a hot and humid environment. I have discussed the “12 Point” cardiac evaluation with the student and parents, performed a physical examination and believe he/she is physically able to participate in athletic and sports activities as described. ** Please print or Stamp ** Examiner’s Name: _________________________________________________________ Address: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Phone: __________________________________________________________________ Examiner’s Signature: ______________________________________________________Date: _______ Page 2 of 2 SUMMER CAMPS at GRANDE SPORTS ACADEMY Items to Bring The following are suggested items at Grande Sports Academy. Bring casual attire for after-sport activities, including: Clothing for Leisure Sweatshirt Running Shoes Other Items: Cell Phone or Phone card for Long-Distance Calls Laptop or “Notebook” with wireless capabilities Personal toiletries Laundry bag Notebook, pen, writing materials, stamps Camera, film and batteries (if desired for sightseeing) Sunscreen Sunglasses Swimsuit Beach Towel Caps/Hat In addition to the above, the following is a detailed list of items for Soccer: Soccer: Training uniforms Soft Ground Soccer Shoes Molded/Standard Soccer Shoes Indoor Soccer Shoes Shin Guards Socks T-Shirt Shorts Uniforms: The training gear will be provided by Grande Sports Academy. Any training gear not returned by student athlete shall be charged full retail rate to student athletes’ credit card that is on file.
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