Registration: NAME: ______________________________________ Director: Tim Walters -Lafayette Head Varsity Boys and Girls Coach AGE:_________________________ -1997 HS Soccer Girls State Champions -12 year professional career with St. Louis Steamers, Wichita Wings, Tampa Bay Rowdies & Ambush - Physical Education teacher in the Rockwood School District - Over 30 years directing and instructing soccer clinics ADDRESS:____________________________________________ When: June 2nd – 5th Time: 9am- 12 noon (M-TH) Price: $70 Where: Lafayette High School PARENTS NAMES: ______________________________________________________ ______________________________________________________ Boys and Girls Going into Grades:  3rd and 4th (Limited to first 20 boys and first 20 girls)  5th and 6th (Limited to first 20 boys and first 20 girls)  7th, 8th and 9th For Your Information:  Open to boys and girls  Bring a soccer ball and water bottle with your name on it  Secondary insurance provided  Each camper will receive a FREE T-SHIRT For more information call: Coach Tim Walters: 314-640-9561 Grade (fall ’14)_____ CITY/STATE/ZIP: ______________________________________________________ PHONE (HOME):_______________________________________ WORK:_______________________________________________ EMERGENCY PHONE NUMBERS:___________________________________________ I hereby release Tim Walters, and his employees from any liability resulting from injury to my child while participating in this soccer camp. ______________________________________________________ (Parent’s Signature) (Date) ***Please submit payment and this form by May 15, 2014. Make checks payable to Tim Walters*** Mail to: Tim Walters 151 Emerald Green Ct. Creve Coeur, MO 63141