Registration Form
Please select a camp:
2009 Summer Fundamental Camp - Option 2 July 6-10 (Day $295/Resident $395) 2009 High School Summer Resident Camp-Option 1 June 8-12 or Option 3 July 21-23 ($545.00) 2009 Fall Clinic -1 Session ($159.00) 2009 Fall Clinic -2 Sessions ($249.00) 2009 Fall Clinic -3 Sessions ($329.00) 2009 Holiday Clinic ($135.00) 2009 Winter Hitting/Infield Clinic ($175.00) U12/U14 2009 Winter Hitting/Infield Clinic ($200.00) U16/U18
E-mail:
Day Phone: Evening Phone:
Age: HS Graduation Year: 2009 2010 2011 2012 2013 2014
Position: Pitcher Catcher First Base Second Base Shortstop Third Base Left Field Center Field Right Field Shirt Size: Men's Small Men's Medium Men's Large Men's X-Large Men's XX-Large
Date of last tetanus shot: Current Medications:
Current Medical Conditions:
Insurance Company: Policy Number:
Roommate Preference- Please list First and Last Name. All attempts will be made to accommodate your requests.
1st Choice:
2nd Choice:
3rd Choice:
Complete the following only if enrolled in 2009 Fall Clinic (1, 2, or 3 Sessions).
I hereby authorize the staff of North Country Camps, Inc. to act for me according to their best judgment in any emergency requiring medial attention and I hereby waive and release the Camp and the University of Minnesota from any and/or all liability for any injuries or illnesses incurred while at Camp or in transportation to a medical facility, except for injury resulting directly from gross negligence or willful misconduct. I have no knowledge of any physical impairment that would be affect by the above named camper's participation in the Camp program as outlined in the brochure. I also understand the Camp retains the right to use for publicity and advertising purposes photographs of campers taken at the Camp.
______________________________________________ Parent's or Guardian's Signature
MEDICAL INFORMATION AND RELEASE OF LIABILITY
Event ___________________________________________________________________________________________
Organization Conducting Event________________________________________________________________________
Participant’s Name _________________________________________________________________________________ (please print)
Address _________________________________________________________________________________________ (street) (city) (state, zip)
Contact person in case of emergency:
Name _______________________________ Relation ___________________________
Phone _______________________________
Medical conditions, impairments and allergies of which the staff of the Organization and/or University of Minnesota should be aware:
__________________________________________________________________________________________________
__________________________________________________________________________________________________ (Insert "none" if none)
* * * * * * * *
I understand and agree that some activities occurring as a part of or incidental to the Event may be of a hazardous nature and/or include physical and/or strenuous activity. Understanding this, I state that I have no medical condition or impairment, including the use of medication that might inhibit my active participation in the Event named above. In the case of an injury or medical emergency, I authorize the staff or employees of Organization and/or the University of Minnesota to render first aid and/or obtain whatever medical treatment he/she deems necessary for my welfare. I further understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of said treatment regardless of whether my medical insurance would cover such charges and fees.
I have read and understand agree to the terms and conditions of this
release.
Print Name ____________________________________________
Signature ______________________________________________ Date __________________
(If participant is under the age of 18, Parent/Legal Guardian’s signature)
I am the parent or legal guardian of the minor _________________________________________ and am signing this release on behalf of the minor. (Print child’s name)
Please print this form and mail it to the address below with your $100 deposit to. North Country Camps P.O. Box 18144 Minneapolis, MN 55418
612-270-2534