Camp Selection

Please make a camp selection.

Big Man Academy (June 11 - 12, 2010) - Pay In Full             $135.00

Please note: All deposits are non-refundable, but are applied toward balance owed.

Choose Your Payment Option

Pay for my child to attend camp.
Pay for another child to attend camp (Gift Certificate).

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)
CVV Code

Parent / Guardian Information

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

Name


First Name
Last Name

Mailing Address


Address

Address Line 2

City
Mailing 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 Age

Camper's Birthday

 /  / 

Camper's Grade in School Next Fall

Camper's Height

Camper's Weight

It is necessary that our doctor has parents' permission to administer treatment in event of an accident or sudden illness.

Medical Information

Emergency Contact

Contact Name 1

Contact Phone 1

Contact Name 2

Contact Phone 2

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)

Insurance Company

Policy Number

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 which may be advised or recommended by the attending physician of my child while at The Citadel. Insurance Coverage of accidental injury is required by all participants. In most instances, family health is adequate. I have the required insurance and am providing the carrier and policy information at this time.

Full Name
Date