Validus RE Specialty Camp Registration *Please fill out this form from top to bottom. Certain details on this form populate depending on the selections that you choose. Thanks! Validus RE Specialty Camp Player InfoLocation of Player(Required) Domestic (From Bermuda) International (Outside of Bermuda) Player Position(Required) Field Player (with Coach David Bascome) Goalkeeper (with Coach William Vanzela) Player Name(Required) First Middle Last Gender Male Female Age(Required) Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Player Cell Phone(Required)Athlete Shirt Size(Required) Youth Small Youth Medium Youth Large X-Small Small Medium Large X-Large Position Camp Date SelectionCamp Date(Required) June 26th - June 30th Cost of Camp Price: *Included in the total cost listed at the bottom.Lodging Accomodations*Note: For international players coming into Bermuda, the costs listed below do not include airfare. Airfare arrangements are up to you to make. We will provide transportation to and from training for the players.Lodging Accommodations(Required) Home (Domestic Campers Only) Number of Occupants(Required) Grotto Bay Single Occupancy - $2835.00 Grotto Bay Double Occupancy - $2926.00 Grotto Bay Triple Occupancy - $3094.00 Grotto Bay Quadruple Occupancy - $3262.00 ** Lodging for international players is calculated for a 7 day stay (arriving on Sunday, June 25th and leaving on Sunday, July 2nd). All prices represent the final price you will pay for lodging and include taxes and fees. For more information on each hotel, see the hotel links below: Grotto BayHiddenUntitled Parental/Guardian InformationGuardian to Enter(Required) Mother/Guardian Father/Guardian (Must select at least 1)Mother/Guardian Name(Required) First Last Email(Required) Cell Phone(Required)Work PhoneHome PhoneFather/Guardian Name(Required) First Last Email(Required) Cell Phone(Required)Work PhoneHome PhoneSignatures, Disclaimers and Terms of AgreementMedical Emergency(Required)I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I agreeMedical Expenses(Required)I understand that the Bascome Enterprise and/or its Staff will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. I agreePhoto Release(Required)I understand the photos will be used to keep a journal of activities, to share during power point presentations, for promotional purposes including flyers, brochures, newspapers and/or reports to our donor Bascome Enterprise. I agreeTerms(Required)The Bascome Enterprise and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. The child’s photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician). I agreeSignature(Required)By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. First Last Date MM slash DD slash YYYY Payment InformationCoupon Single or Recurring Payment(Required) Single Payment Down Payment of $500 Now, Remainder on May 1st, 2023 For recurring payments, you can choose either to pay in one single payment or to break up your payment into two parts. For the two part payment, you are first charged $500 when completing your registration and the remaining amount will be charged to you on May 1st, 2023.Total HiddenQuantityPlease enter a number from 0 to 1.Down Payment Price: Credit Card(Required) Cardholder Name Card Details Email Address Where You Would Like to Receive Your Receipt(Required) Payment Terms(Required)Payments All payments MUST be received prior to the players starting. Players not paid will not be able to play or train until payments have been made. Registration Deadlines All payments MUST be received prior to the start of training. I agreeSignature(Required)By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. First Last **Please double check that all fields are filled out properly before submitting your information. An incorrect submission will require you to RELOAD THE PAGE and enter all of your information again!**EmailThis field is for validation purposes and should be left unchanged.
