2009 Blue Hen Junior and Day Field Hockey Camps Registration Form |
STUDENT'S NAME ____________________________________________________ |
AGE _________ HEIGHT_________ WEIGHT__________ GRADE TO BE ENTERED IN THE FALL _________ |
SCHOOL__________________________________ FIELD HOCKEY POSITION_____________________ |
E-MAIL ADDRESS (required for confirmation)_________________________________________________ |
HOME ADDRESS ___________________________________________________________ |
CITY ___________________________ STATE ________ ZIP CODE _________________ |
HOME PHONE: (_______) _________ - ___________ EMERGENCY PHONE: (_______) _________ - ___________ |
EXPERIENCE: |
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T-SHIRT SIZES: UNISEX FOR DAY CAMP, YOUTH SIZE FOR JUNIOR CAMP |
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ENCLOSED IS MY CHECK FOR FULL PAYMENT OF: |
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Make Check Payable to: CAROL MILLER, TA |
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VARSITYPART 2. EMERGENCY HEALTH INFORMATION |
PARENT #1 NAME _______________________________________ DAY PHONE (_______) _________- _________ |
PARENT #1 PLACE OF EMPLOYMENT_______________________________________________ |
PARENT #2 NAME _______________________________________ DAY PHONE (_______) _________- _________ |
PARENT #2 PLACE OF EMPLOYMENT________________________________________________ |
IF PARENT OF GUARDIAN CANNOT BE REACHED CALL: __________________________________________ |
PHONE (________) _________ - ________________ |
MY FAMILY PHYSICIAN: ________________________________ PHONE: (_________) __________-_____________ |
MEDICAL HISTORY (EXPLAIN THOROUGHLY ANY YES RESPONSES-Enclose note for longer explanations.) |
Any medical conditions currently under treatment?___________________________________________________________ |
Any pre-existing injury currently under treatment?: __________________________________________________________ |
Any Asthma and/or allergies (including drugs, food etc.)? ______________________________________________________ |
Any mental disorders or convulsions?_____________________________________________________________________ |
Any Past illness of more than one week in duration? _________________________________________________________ |
Contact lenses or glasses?____________________________________ |
Medical Insurance Company________________________________________________ Policy Number________________ |
MEDICAL INFORMATION & AUTHORIZATION TO PARTICIPATE -- REQUIRED FOR ADMISSION: _________________________has been examined within the last 12 months and no medical reason has been found that she/he cannot participate in this camp. Her/his records show that all immunizations are up to date. Date of last tetanus and diphtheria immunization___________________, (If more than ten years ago, a booster is recommended). I agree that in case of an accident involving my child while attending this camp and with full awareness that field hockey is an activity that may involve risk of injury, I release the Blue Hen Field Hockey Camps; T.A. Carol Miller and the University of Delaware from any and all liability for any injuries or illnesses incurred while at camp. In case of an emergency, I give permission to the appropriate summer camp personnel to have my child properly transported to a medical facility for care. I understand that the Blue Hen Field Hockey Camp; TA Carol Miller and the University of Delaware does not provide medical insurance and that I will be responsible for all medical expenses incurred. This camp has adopted the following procedures in caring for your child when she/he becomes sick or injured while attending camp. (1) The camp will call home, if there is no answer (2) The camp will call the father's, mother's or guardian's place of employment, if there is no answer (3) the camp will call the other phone numbers listed and the physician . (4) If none of the above answer, the camp will call an ambulance, if necessary, to transport the child to a local medical facility. (5) Based upon the judgment of the attending physician, the child may be admitted to a local medical facility (6) The camp will continue to call the parents, guardian and physician until one is reached. If I cannot be reached and the camp authorities have followed the procedures described, I agree to assume all expenses for moving and medically treating the camper. I also hereby consent to any treatment, surgery, diagnostic procedures or the administration of anesthesia which may be carried out based on medical judgment of the attending physician. By signing below, I agree to all the terms detailed above. |
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____________________, 2009
PARENT/GUARDIAN SIGNATURE
DATE
POLICIES:
The Blue Hen Field Hockey Camp, its director and/or staff reserves the right to dismiss anyone from camp who has acted inappropriately. A camper whose behavior has been deemed inappropriate and/or does not abide by camp rules, will be required to depart camp as soon as parents have been notified and transportation is secured. Campers are not allowed to depart from the fields, field house arena and/or pool with out permission from director or staff.
THE BLUE HEN FIELD HOCKEY CAMPS ARE INDEPENDENTLY RUN AND NOT UNIVERSITY OF DELAWARE PROGRAMS.
PAYMENT POLICY
Payment in full must accompany registration form and must be received at least three full weeks prior to opening day of camp ($100.00 of this will be considered a nonrefundable deposit) NOTE: Camp will fill on a first come first serve basis. Early registrations are strongly encouraged. Without advanced reservation and payment, participation cannot be guaranteed. There is a $30 charge for all returned checks.
REFUND POLICY:
A request for refund must be submitted in writing prior to August 1, 2009. No refund requests will be taken after this date. The nonrefundable deposit of $100.00 will be deducted for administrative expenses. No refunds will be issued until camp has ended.
FOR INFORMATION: camp2008@bluehenfhcamps.com; Blue Hen Elite Field Hockey Camp, 472 Haystack Drive, Newark, DE 19711; 302-366-1005; www.bluehenfhcamps.com