JBSA Online Registration

Please complete a separate form for each child. If you have already submitted a registration for your child this year, please do not re-submit the form below. If you would like to add a week to an already existing registration, please email John Bouman at jbsoccer@howardcc.edu. Thank you.

Session(s) In Which You Wish To Enroll (please check):
June 23 - 27
(FULL) June 30 - July 3 (Advanced Players Only)
(FULL) July 14 - 18 (Advanced Players Only)
(FULL) July 21 - 25

Name of Camper:
First Name:      Last Name:

Age as of First Day of Camp:

Gender:
Male Female

Parent/Guardian:

Street Address:

City:

State:

Zip Code:

Day Phone:

Evening Phone:

Cell Phone:

E-mail Address: (Your email address will be used for JB Soccer Academy purposes only, and will NOT be shared with outside organizations).

Emergency Contact Name:

Emergency Contact Phone Number:

Name of Physician (or HMO):

Phone of Physician (or HMO):

Health Insurance Carrier:

Allergies Or Other Medical Conditions Of Which Our Trainer Should Be Aware:

Medications your child will be taking during camp. Please note: per a recent Maryland law change, our trainer and staff are no longer permitted to administer medicine and sunscreen. Please instruct your child to administer her/his own medicine, or have a parent or guardian visit the camp to do so.

Date (Year) Of Last Tetanus Shot (this information is required per Maryland Department of Health and Hygiene Regulations):

School of Camper: (Maryland health regulations require that campers have updated immunizations records. If your child does NOT attend a public or private school, please provide proof of immunization. If, for religious or other reasons, you have chosen not to immunize your child, please provide documentation.).

The Following Adult(s), Other Than Parent, Has My Permission To Pick Up My Child:


My Child is Part of the Kids on Campus Program During the Week She/He is Enrolled in the JBSA:
Yes No
If you are part of the Kids on Campus program, please select when you will be attending the JB Soccer Academy:
Morning Afternoon

My Child is Part of the 5/6 Year Program (8:30 - 11:15):
Yes No

Please Check:
My Child Has My Permission To Walk, Bike, Take A Bus Or Use Other Transportation to Go Home
My Child Would Like Field Player Training (Available All Sessions)
My Child Would Like Goalkeeper Training (Last Week Only)
My Child Would Like A Combination of Field Player and Goalkeeper Training (GK training only during the last week)

I Allow my son/daughter to Appear in Camp Pictures Used For The JB Soccer Brochure or Web Site.
Yes No

Number of Years Your Child Will Have Attended the Camp After This Year:

Comment Box (Other Information or Special Requests)

Please check one or more of the following options:
Wind-down (4:00-6:30pm), or Before-care (7:30 - 8:30 am). Please specify in the comment box if you will register for Wind-down or Before-care or both. You must sign up separately with the wind-down/before care office at Howard Community College to reserve your space. Please call RSAI at 410-772-4587 to register or for more information. An adult staff member will walk your child from before care to the JB Soccer Academy in the morning, and/or from the JB Soccer Academy to the wind-down room in the afternoon.
JB Soccer Academy Ball - $20

After submitting this form, please make a check payable to "Howard Community College", write the name of the camper and the week(s) that you registered on the check, and mail it within 7 working days to:
JB Soccer Academy
P.O. Box 693
Clarksville, MD 21029

Credit Card Payments:
We are now accepting VISA, MasterCard, American Express and Discover credit cards. If you would like to pay by credit card, please call 410.772.4873 and leave your card number, the expiration date, the amount, the name on the card and your phone number on the voicemail. If you feel more comfortable and secure, feel free to leave part of your credit payment information on the above voicemail and another part via email (jbsoccer@howardcc.edu).

If we have not received your payment within 7 working days, we may delete your enrollment and you may need to register again. Please call 410.772.4873 if you enroll, but change your mind, or if you should have any questions.

Please remember to subtract your tuition discount if you are enrolling more than one child or enrolling for more than one week or enrolling a member of a team (indicate this on your check please). For an example of your tuition calculation, Click Here.

Waiver:
By pressing the submit button below, I affirm that my daughter/son is in good health and may participate in all the JB Soccer Academy’s activities. I grant permission for my daughter/son to be given treatment at a local hospital and/or by the certified HCC trainer, if deemed necessary. I hereby waive all claims, costs and liabilities against the JB Soccer Academy, Inc., Howard Community College Staff, and Howard Community College and its respective officers, trustees and representatives arising out of the natural risks inherent in the nature of the activities and participation in the program.

(Please press the submit button below once to register)

If you are registering more than one child press the back button after submitting the form and modify as needed. Then press submit again for your second registration.