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2006 CAMP APPLICATION The Application and Waiver and Release on the next two pages may be printed, completed and mailed (with your deposit) to: ISU Women's Basketball Summer Camps, Indiana State University, Arena, Suite 107, Terre Haute, IN 47809, Telephone: (812) 237-8357
Camp Application Name:____________________________________________________________________
City___________________________________State__________Zip__________________ Birthdate: Month_____Day_____Year____ Age______ Grade (Next Year)______ School______________________________________________________________ Parent/guardian (Please Print):___________________________________________ Parent/guardian signature_______________________________________________ T-Shirt Size (please circle one): Adult S Adult M Adult L Adult XL Youth M Youth L In case of an emergency contact me at (phone number) Work_______________________________________ Home______________________________________ (Check One) ______Youth Day Camp (June 19-22; 9 a.m. - 4 p.m.) Amount Enclosed: $135___ ______High Intensity Camp (June 26-29) Amount Enclosed: Resident $250 ___ Commuter $200 ___
Waiver and Release
NAME OF CAMPER______________________________________________________ In consideration for my daughter's participation in the Indiana State University Women's Basketball Summer Camps, I hereby agree and promise that I will not hold Indiana State University nor its employees responsible for any loss, damage, or personal injuries that she may receive as a result of participation. Signature (Parent/Guardian)_________________________________ Date____________ I/We being the parents and/or legal guardian of the applicant, authorize the Indiana State University Women's Basketball Summer Camp and its agents to request emergency medical treatment or care as necessary to ensure the well-being of our dependent. Further, I claim that the registrant has had a physical examination in the past year and was found fit for all physical endeavors. Signature (Parent/Guardian)_________________________________ Date____________ Additional Information Drug/Food Allergies______________________________________________ _____________________________________________________________ Date of Last Tetanus Immunization_________________________________ _____________________________________________________________ Current Medications_____________________________________________ _____________________________________________________________ Physical Restrictions____________________________________________ _____________________________________________________________ Any other concerns our staff should know___________________________ _____________________________________________________________
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