Camp Selection

Please make a camp selection.

Youth Camp - June 20 - 23, 2011 - Pay In Full $160.00

Youth Camp - June 20 - 23, 2011 - Deposit $50.00

High School Camp - June 20 - 23, 2011 - Pay In Full $250.00

High School Camp - June 20 - 23, 2011 - Deposit $100.00

Please Note: All deposits are non-refundable

Billing Information

Name as it appears on credit card


First Name
Last Name

Billing Address


Address

Address Line 2

City
Billing State

Zip Code
Country

Telephone Numbers


Home Number

Work Number

Cell Number

E-Mail Address

Credit Card Information


Type:   Visa     Master Card     American Express     Discover   


Credit Card Number
 / 
Expiration (mm/yyyy)

Parent / Guardian Information

Check this box if the following information and your billing information are the same.

Name


First Name
Last Name

Billing Address


Address

Address Line 2

City
Billing State

Zip Code
Country

Telephone Numbers


Home Number

Work Number

Cell Number

E-Mail Address

Camper Information

Camper's Name


First Name
Last Name

Camper's Gender

Camper's Age

Camper's Birthday

 /  / 

School, Coach, and Additional Information

School

Coach

Club or other affiliations?

Other Sports

Medical Information

Emergency Contact

Contact Name

Contact Number

Health Insurance Provider for Camper

Policy Name (Whose name is the policy filed under?)

Date of Last Tetanus Shot

Allergies, Medications, or Other Conditions (please list anything you'd like us to be aware of in case medical treatment becomes necessary)

Medical Authorization

By clicking on the box to the left and entering my name and today's date into the fields below, I hereby authorize any medical treatment for my child that may be advised or recommended b y the athletic trainer hired for the camp at Davidson College or by an emergency room medical staff.

Full Name
Date

Photographic Release

By clicking on the box to the left and entering my name and today's date into the fields below, I hereby agree to the following statement: For Good and valuable consideration, the receipt of which is hereby acknowledged, I (as the parent or legal guardian of the camper named in this application) hereby grant and convey to Davidson College all right, title, and interest in and to record my child's name, likeness, image, voice, statements, and/or writings including any and all photographic images and video or audio recordings made by Davidson College. I further grant to Davidson College, its advertisers, customers, agents, successors and assigns, unrestricted rights to use the above mentioned sounds, still, or moving images in any medium, including but not limited to, external or internal print media or posting on the Internet and World Wide Web, for educational, historical, archival, promotional, advertising, or other purposes, without limitation, consistent with the mission of the College. I agree that all intellectual property rights to the sound, still, or moving images belong to Davidson College. I voluntarily waive any right to any royalties, proceeds or other benfits derived from such photographs or recordings and agree that I shall receive no compensation from my/or my child's appearance and participation.

Full Name
Date