Brazilian Winter Clinic/Summer Camp/Trip to Brazil (Brazil Trip Registration Form - PDF)

I hereby state that my child is in good normal health to participate in the Brazilian Winter Clinics.  I authorize Mani Santos and his staff to act for me according to the best judgment in any emergency requiring medical attention in the event of illness or injury.  I release Mani Santos, his staff from any and all liability in case of any accident and hospitalization while my child is attending the Brazilian Winter Clinics.

Fees are not refundable if the player quits after registration.

Parent's Name: ____________________________________

Parent's Signature:  _________________________________

Address:   _________________________________________

Phones #: _________________________________________

E-mail:  ___________________________________________

Player Name: ______________________________________

Age Group: __________

Birth Date: ________________

Health Insurance Co:  __________________

Policy #: _______________________

Doctor's Name: __________________________

Phone #: ________________________

Week: _________________________

FEES: $_____________

Please, send the Application to:
Mani Santos
2335 London Bridge Drive
Silver Spring, Maryland 20906