2012 GREAT WESTERN GIRL'S CAMP APPLICATION

Campers Name_______________________________________ Position: _____________________________
Address_________________________________________________ City_______________________________

State____    Zip Code_____________    Age_____      DOB____________   Grade Completed 6/12 _______

School_____________________________________ Roommate______________________________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Day Camper_______                      Overnight Camper _______                             

Parent Email___________________________________________________________________ (Mandatory)  

I am Sending $25.00 Ins Fee as a non-US Lacrosse Member_____________

My US Lacrosse Membership Number is _____________________________  Exp. Date________________
 (If you leave the above blank, you MUST send the $25.00 Insurance fee with the application)

Sending the Airport Transfer Fee of $40.00 (check here)_____RT   $25.00          One-Way   
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 
I understand that: 1) My child is in good physical condition and has had a physical examination within six months prior to camp; 2) I am hereby waiving and releasing the Great Western Lacrosse Camp, its Director and its Staff from any and all liability for injuries incurred by my child while attending and participating in Camp even if arising from negligence; 3) I will pay all costs incurred by the Camp as a result of any failure by my child to respect and maintain facilities and/or observe Camp rules and regulations; 4) The Camp and its Director are not responsible for my child prior to check-in and after check-out; 5) If my child is found to have possession of drugs, alcohol or weapons on the Camp premises, my child will be sent home immediately and without any refund of fees; In the event that I am unable to give parental consent, I hereby authorize the Physician/Hospital Staff at the nearest Hospital to provide care to include diagnostic procedures and medical treatment as necessary to my child, who is a minor.
( Leave nothing blank )

Parental Signature__________________________________________________ Date_____________________

Print Parents Name__________________________________________________

Parents Home Phone______________________________ Work Phone________________________________

Medical Insurance___________________________________________ Policy Number____________________

Emergency Contact (Not Parent)____________________________________ Phone_______________________

I have enclosed a check/money order in the amount of $_______ to secure my child a position at the Great Western Girls Camp. By signing above, 
I understand that my deposit of $300.00 or that portion of my full payment is completely NON-REFUNDABLE after July 1st, 2012.   

I have paid my fees online by credit card in the amount of $_______ to secure my child a position at the Great Western Girls Camp. By signing above,  I understand that my deposit of $300.00 plus the service fee or that portion of my full payment and service fee is completely NON-REFUNDABLE after July 1st, 2012.
_______________________________________________________________________________________________________________________
Office Use Only - Do Not Write In This Section
 Full/Deposit____________________ Date______________  Check #______________
 
 Insurance Fee______________  Travel Fee________________  Store Account__________________