2010 KEYSTONE STATE GIRLS TEAM CAMP APPLICATION
PLEASE CHECK CAMP SITE & DATE YOUR TEAM IS ATTENDING:
At Edinboro University, Edinboro, PA
[ ] July 16 - July 18 (3-day) $180 if paid in full by 6/15
[ ] July 16 - July 19 (4-day) $260 if paid in full by 6/15
At Bloomsburg University, Bloomsburg, PA
[ ] July 26 - July 30 (5-day) $370 if paid in full by 6/15
At Swarthmore College, Swarthmore, PA
[ ] July 23 - July 25 (3-day) $180 if paid in full by 6/15
(Print Clearly!)
Address ________________________________________ City_________________________ State _____ Zip _____
Home Phone (______)__________________________ Cell Phone (_______)_______________________
Email Address _________________________________________________________________________________
Grade in Sept 2010 __________ School in Sept 2010 ____________________________________________________
High School Coach ____________________________
Height __________ Weight _________ Tee-shirt Size: S M L XL
(Teams will room together – 2 in a room; at least 8 players must attend camp; you choose your roommate)
3-day Camp at Swarthmore - $180 if paid in full by June 15, $205 after June 15
3-day Camp at Edinboro - $180 if paid in full by June 15, $205 after June 15
4-day Camp at Edinboro - $260 if paid in full by June 15, $285 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, 4 or 5-day camps.
(To avoid a $5 Application Return Fee, FILL OUT COMPLETELY!!)
I understand that Keystone State Camps does 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 # ___________