Child #1:
Boy: Girl: Date of Birth (mm/dd/yy):
Camper's USCF Rating / Level:


Child #2:
Boy: Girl: Date of Birth (mm/dd/yy):
Camper's USCF Rating / Level:


Child #3:
Boy: Girl: Date of Birth (mm/dd/yy):
Camper's USCF Rating / Level:



Parent Name:
Home Phone# Work Phone#
Email Address:
Address:
City: State: Zip Code:

Name(s) of Parent(s) Attending Camp:

Cabin Mate Request(s):
(Cabin mates must be similar age. Request must appear on other camper's application)


Fee Schedule: (Please check appropriate categories and calculate quantities)

July 26 - 30, 2010, - $525 per Camper, $400 per Parent
$50 deposit per camper/parent – due with enrollment form
(balance due by 7/20/10)

Number of Children: Number of Parents:


Purchase a T-Shirt:
(T-Shirts will be waiting for you at the Camp)

Size of First T-Shirt (Additional $15): -- Small Medium Large X Large XX Large

Size of Second T-Shirt (Additional $15): -- Small Medium Large X Large XX Large

Payment Method:
Visa Mastercard Discover
Credit card number: Exp (mm/yy):
Three Digit Code on the Signature Panel on the back of the card:
NAME (as it appears on credit card):


I approve this application and certify the applicant(s) capable of such an experience. I agree to have the health history form(s) completed prior to the beginning of camp. Camp fees are not refundable without medical authorization. No refunds are given if a child leaves early because of home sickness or for disruptive behavior as decided by the camp director. The deposit is not refundable for any circumstances. I grant permission for the applicant(s) to participate in all camp activities understanding that competent leadership will be provided. In case of accident or illness, the camp is authorized to secure emergency medical treatment. The camp is not responsible for lost, stolen or damaged personal articles. I authorize the camp to have and use photographs, slides and video tapes of the person(s) names on this application.