APPLICATION FOR SUMMER PROGRAM 2015
DATE:
APPLICANT INFORMATION
Name:
Last
Street Address:
City
Date of Birth:
Email:
Middle
First
State
Zip
Male:
Female:
Contact Number:
PLAYING EXPERIENCE
HIGH SCHOOL
CLUB
CLUB
ODP
COLLEGE
TEAM NAME
CITY/STATE
COACH’S NAME
LEVEL PLAYED
POSITION
YEARS PLAYED
Please list any additional awards or honors you have received during your soccer career
I certify that information contained in this application is true and complete. I understand that false information
may be grounds for not accepting me or for immediate termination from the program at any point in the future if I
am accepted to the program. I authorize the verification of any or all information listed above.
Signature:
Date:
KEEPER ASYLUM LIABILITY WAIVER
WAIVER: Neither the KEEPER ASYLUM LLC, the founders, nor anyone else connected with the camp
assumes responsibility for accidents or any other injuries incurred as a result of attendance at this camp.
My parent or guardian authorizes the director of the camp to act in his best judgment in any emergency
requiring medical attention. I understand that applicants are required to have health/accident insurance
coverage while at camp.
I acknowledge that I understand the content of this document. I am aware that it is legally binding and I
sign it out of my own free will.
__________________________________________________
Applicant’s signature
__________________________________________________
Parent or guardians signature
__________________________________________________
Health and accident insurance company
__________________________________________________
Policy #
__________________________________________________
Emergency Contact Name and Phone Number
KEEPER ASYLUM DEPOSIT
A NON-REFUNDABLE DEPOSIT OF $100.00 IS REQUIRED WITH EACH APPLICATION. PLEASE MAKE
CHECKS PAYABLE TO KEEPER ASYLUM, LLC. BALANCE OF PAYMENT (Additional $149.00) DUE ON FIRST
DAY OF CAMP. CANCELLED DEPOSIT CHECK WILL SERVE AS CAMP CONFIRMATION.
Keeper Asylum will take place on July 27 through July 30, 2015. Keepers will be placed in a group either
from 9 AM-Noon or 1 PM-4 PM based upon proper ability groupings.
If you are not 100% satisfied with the camp experience, you are entitled to a no-hassle full refund.
MAILING INSTRUCTIONS
Please mail completed application, along with check, to:
Keeper Asylum LLC, 50464 Waterstone Court, Plymouth, MI 48170.
Select a size (adult sizes) for your goalkeeper: Small
Medium
Large
Extra Large (Circle one.)