Please Circle: Field Player  or  Goal Keeper

Name of Camper:___________________________________ Age____ HT____ Grade____ (Fall’11)

Adult Shirt Size: S   M   L   XL

Street Address:_______________________ City:____________ State:___________ Zip:____________

Home Phone:________________________

Emergency Phone:____________________

Email Address:________________________

Parent/Guardian:_______________________

Parent/Guardian Authorization: _____________________ I herby approve of my child’s attendance to Crystal Carper's Field Hockey Camp and certify that she is in good health and able to participate in the program. I authorize that the director act for me according to her best judgment in any emergency requiring medical attention. I understand, should an emergency condition arise, I will be contacted during the physical exam. If I am not available, I authorize you to contact: _________________________________

Name of Physician:______________________________

Phone #:___________________

Health Insurance Carrier Policy #:___________________

Signature of Parent/Guardian:______________________ Date:___________


Day Camp
I am enclosing a $100.00 Day Camp Payment: YES     NO (please see below)

*If you are not enclosing payment please be aware that there will be an additional 10.00 fee at check-in.
 
***Camp registration forms will be accepted from Now – June 15th. If there is space available, registration forms will be accepted on site and also payable by cash only for a total fee of $110.00.

Mail Application to: CC Field Hockey
                            P.O. BOX 5005
                            Ashland, VA 23005