LOCK HAVEN UNIVERSITY WRESTLING

2009 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. '09:  _____________  
High School:  ______________________________________ Resident Camper q Commuter q
Coach's Name:  _________________________________    
Roommate(s) Preference: _________________________ _________________________
  _________________________ _________________________
  _________________________  
The first 350 campers to register for the Team Camp at Shippensburg University and pay in full will be housed in six-person and four-person air conditioned apartments.  Those campers registering for the Intensive-Technique Camp at Lock Haven University will be housed two to a room.  Please plan roommates accordingly. 

Check the camp you will attend:
at Lock Haven University 
q  Intensive-Technique Camp
q  Elementary Day Camp
 at Shippensburg University
q  Senior High Team Camp
q  Junior High Team Camp

Please check your housing option:
q  Commuter (No Housing) - $310
q  Resident - $360
q  Elementary Day Camp  - $125
q  Coach/Parent - $200
 

Check method of payment:
(If paying with credit card, payment MUST be in full.)
q  Check  (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.)
o  Automatically deduct $50 if registering before April 1, with deposit.
o  Automatically deduct $25 if registering April 1, to May 1, with deposit.

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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