CAMP INFORMATION
Camp Dates:
  

 
CAMPER INFORMATION
Name:
Father's Name:
Address:
Phone (home):
   (work):
City:
   State:
Zip :
Mother's Name:
Birth Date:
   Email:
Phone (home):
   (work):
 
T-Shirt:
S M L XL XXL
Roommate:
     
INSURANCE INFORMATION
  
For emergencies, Contact Name:
Contact Phone:
Athlete's Physician Name:
Physician Phone:
Date of last tetanus toxoid:
Allergic Reactions ?
Medication presently taking:
Insurance Company:
Any instructions regarding your insurance:  
Insurance Phone:
Past illness or other information that would be useful in the event treatment is necessary :

*REGISTRATION WILL NOT BE COMPLETED UNTIL PAYMENT THROUGH PAYPAL IS SUBMITTED AND CONFIRMATION IS RECEIVED.  
ONLY SUBMIT REGISTRATION WITH PAYMENT.

*CANCELLATION WILL RESULT IN A $100 PROCESSING FEE.  NO REFUNDS WILL BE GIVEN AFTER THE START OF CAMP.