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 mkline@grandesports.com 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
___
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__________
__________
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__________
__________
__________
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
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__________
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__________
__________
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__________
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__________
__________
__________
__________
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.