TEAM CAMP REGISTRATION FORM
 

_______________________       ______________________       ____________________
              Last Name                           First Name                           Middle Name
 
__________________________      ___________________      _____      ___________
        Street Address                               City                     State         Zip Code
 
  (____)_____________           _____________________________     (____)__________
       Home Phone #                           Emergency Contact                    E. C. Phone  
      
_______________________________   __________________      __________________
                     School Name                    Offensive Position             Defensive Position
 
Make checks ($250) payable to Championship Team Camp
Mail Check and Registration form to:
Rich Hunter
1682 Pioneer Rd.
Lancaster, PA 17602
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Emergency Release Form (Completed by a parent or Guardian)
 
 
________________     ___________________     ___________________     _____________
                 Player’s SS #                   Last Name                      First Name                 Middle Name
  
(____)____________________________      (___ )______________________________
        Mother’s Daytime Phone #                             Father’s Daytime Phone #
 
In the event that I am unavailable for the purpose of providing parental consent, I hereby authorize the physician and staff at the local hospital to provide such care that routine diagnostic procedures and medical treatment as necessary to my minor son/daughter. I understand the consent and authorization herein granted do not include major surgical procedures and are only valid during camp.
Physical conditions that the physician should be aware of: (i.e. Allergies etc.)
___________________________________________________________________________________________
 
Date of most recent tetanus shot ______________ (If more than 10 yrs. ago, a booster is recommended.)
 
If I am not available, contact ______________________________________ Phone # (____)_________________
 
My family physician is __________________________________________ Phone # (____)_________________
 
Name of insurance company _________________________________________________
 
Policy # ____________________________   Group # ___________________________
 
Father or Mother’s name that the insurance is under ________________________________
Insured Birth Date _____/_____/_____
 
__________________________________   _____________________________________   _____/_____/_____
  Parent/Guardian’s Name (Please Print)                                Signature                                    Date    
 
This camp does not provide medical insurance for campers. In the event of illness or injury requiring treatment or hospitalization, family medical insurance must be used. Parents will be billed directly for any medical care given.