2010 KEYSTONE STATE BOYS TEAM CAMP APPLICATION
PLEASE CHECK CAMP SITE & DATE YOUR TEAM IS ATTENDING:
At Edinboro University, Edinboro, PA
[ ] July 9 - July 11 (3-day) $175 if paid in full by 6/15
At Swarthmore College, Swarthmore, PA
[ ] July 30 - Aug 1 (3-day) $175 if paid in full by 6/15
(Print Clearly!)
Address ________________________________________ City ____________________ State _____ Zip ________
Home Phone (______)__________________________ Cell Phone (_______)_______________________
Email Address_________________________________________________________________________
(Teams will room together – 2 in a room; at least 8 players must attend camp; you choose your roommate)
3-day Camp at Edinboro University - $175 if paid in full by June 15, $200 after June 15
3-day Camp at Swarthmore College - $175 if paid in full by June 15, $200 after June 15
Make Check or money order payable to KEYSTONE STATE CAMP.
No Personal Checks will be accepted after June 15 or at Check-in for the 3-day camps at Edinboro University and Swarthmore College.
(To avoid a $5 Application Return Fee, FILL OUT COMPLETELY!!)
I understand that Keystone State Camps, Edinboro University, and Swarthmore College do not carry medical or accident insurance for students.
I hereby certify that my child, ______________________________________ ,is covered by a personal insurance policy or is included in a policy
that I have in force. Further, I hereby authorize medical dispensary care for the above-named student, and I AUTHORIZE TREATMENT NOT CONSIDERED ROUTINE TO BE REFERRED TO LOCAL PHYSICIANS and MEDICAL FACILITIES AT MY OWN EXPENSE.
The following information is pertinent in case of injury. Do not return the application if the information is not complete or if this application is not signed. If you do not have medical insurance, call 570-323-2072 and ask for a WAIVER to be sent to you.
(Print Clearly!)
Parent’s Name ______________________________________ Parent’s Daytime Phone (_________)______________________________
Address ___________________________________________ Email ________________________________________________________
City__________________________________________ State _________________ Zip _________________________________
Medical Insurance Company ________________________________________________________________________________________
Medical Policy Identification No. ** __________________________________ Group # _______________________________________
Check here if you do NOT have insurance for your child _______
Parent’s Signature ____________________________________________________________________Date _______/________/2010
(MUST BE SIGNED!)
** If no policy number, please explain here: _____________________________________________________________________________
Return this application with Full Payment or $75 NON-REFUNDABLE Deposit to:
Keystone State Camps, 7 Hemlock Road, Williamsport, PA 17701
Do not staple check—Please use paper clip if possible
Amount Enclosed _______________ Name on Check ___________________________________ Check # _______________