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| NORTH COUNTRY SOFTBALL CAMPS |
| Lisa Bernstein and Julie Standering |
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 | Registration Form 2010 NORTH COUNTRY SOFTBALLCAMPER INFORMATION Home Address___________________________________________________
Phone Numbers: Cell______________ Work_____________ Home_____________ Primary Position________ Secondary Position_______ (catchers-bring your own gear) Insurance Company____________________ Policy Number__________________
Date of Last Tetanus Shot_________ Current Medications___________________________________ Current Medical Conditions_____________________________________________ 2010 CAMP PRICES Please Select the Camp you are applying for... [___] 2010 Rookie Camp-June[_]$129 July[_]$189 August[_]$249
[___] 2010 Junior Camp- June[_]$129 July[_]$189 August[_]$249 [___] 2010 Pitching Camp-- (4th-8th Grade) June[___]$79 July[___]$116 August[___]$159
[___] 2010 Pitching Camp-- (9th-12th Grade) June[___]$79 July[___]$116 August[___]$159
[___] 2010 Advanced/Elite Skills Camp-- July [_]$269 August[_]$359 2010 FALL CLINICS-Please write in the skill for your camp time spot: [___] Monday- Clinic A (6:15-7:15p) ____________________ Clinic B (7:15-8:15p) ____________________ [___] Tuesday- Clinic A (6:15-7:15p) ____________________ Clinic B (7:15-8:15p) ____________________ Cost 1-Clinic $140.00 (7 hrs) / 2-clinics $245.00 (14 hrs) 2010 CAMP DEPOSIT AMOUNTS Rookie / Junior Camps- June $75 July $75 August $150 Pitching Camp- June $50 July $75 August $100
Advanced/Elite Skills Camp- July $150 August $200
FALL CLINIC 1- Clinic-$100.00 / 2- Clinics-$150 Please print registration form and waiver and mail to the address below with your deposit to:
Julie Standering - North Country Camps 981 Lydia Dr Roseville, MN 55113
612-741-4097 cell
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 North Country Camps, Inc. 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 North Country Camps, Inc. 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 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)
2010 NORTH COUNTRY SOFTBALL CAMPS |
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