LOCK HAVEN UNIVERSITY WRESTLING

2010 SUMMER CAMP APPLICATION

An application must be filled out for EACH PERSON attending the wrestling camp (campers, parents and coaches).  This form may be duplicated.  Print this application, complete it and send with full payment to:

Wally Kocher, Wrestling Office, Lock Haven University, Lock Haven, PA  17745

 Name: _______________________________________

Male   q

Female   q

Student q

 Coach q

Address:  _______________________________________________________________________

City:  _______________________________________ State:  _____________ Zip:  __________
Home Phone:  (_______)__________________ Parent's Work Phone:  (_______)______________
Email Address: _____________________________________________________________
Cell Phone: (_______)__________________ Coach's Phone: (_______)__________________
Age:  __________________   Weight:  _______   Grade in Sept. '10:  _____________  
High School:  ______________________________________ Resident Camper q Commuter q
Coach's Name:  _________________________________    
Roommate(s) Preference: 1st choice_________________________ 2nd choice________________________

Please check the camp and housing status that applies to you:

Elementary Kids Camp - June 26-29
 q  Resident -$330
q  Resident Sibling or Parent - $230
q  Commuter - $250
q  Commuter Sibling or Parent - $175
Team Camp I - July 11-15
q  Resident - $340
q  Commuter - $240
q  Coach or Parent - $200
Team Camp II - July 16-20
q  Resident - $340
q  Commuter - $240
q  Coach or Parent - $200
 

Check method of payment:
(If paying with credit card, payment MUST be in full.)
q  Check or Money Order  (Made payable to LHUF Wrestling)
q  Credit Card:  _____  Master Card     _____  VISA
Credit Card Number: 
___ ___ ___ ___   ___ ___ ___ ___   ___ ___ ___ ___   ___ ___ ___ ___

Card Expiration Date:  _____ / _____

 Card Identification Number:  ______  (The last 3 digits of the number printed in the signature plate on the back of the card.)


Total Amount Enclosed:.................... $  __________

Liability Release:
I, the undersigned, individually and as a parent / guardian of ___________________________ (Camper) a minor, ask that he / she be admitted to participate in the sports camp sponsored by the Lock Haven University Foundation.  I do hereby agree to release, discharge and hold harmless Lock Haven University, Lock Haven University Foundation, their owners, agents and employees of and from all causes, liabilities, damages, claims or demands whatsoever on account of any injury or accident involving the said minor arising out of the minor's attendance at the sport cam or in the course of competition and / or activities held in connection with the sport camp.  I also give permission for my child's photograph to appear in promotional material regarding future camps.

Parent / Guardian Signature:  _______________________________________________________________

FOR OFFICE USE ONLY:
Rec ________   Check No.  ________   Amt  ________   Disc  ________   Bal  ________   Comp ________

Lock Haven University, a member of the State System of High Education, is an equal opportunity/affirmative action employer and encourages applications from minorities, women, veterans, and persons with disabilities.

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