Blue Hen Field Hockey Camps - Elite Registration Form

2010 The ULTIMATE Overnight Blue Hen Field Hockey Camp Registration Form

PART 1. PLAYER INFORMATION

STUDENT'S NAME ____________________________________________________

AGE _________ GRADE TO BE ENTERED IN THE FALL _________ (MUST BE AT LEAST 9TH GRADE)

HIGH SCHOOL__________________________________ FIELD HOCKEY POSITION_____________________

E-MAIL ADDRESS (required for confirmation)_________________________________________________

HOME ADDRESS ___________________________________________________________

CITY ___________________________ STATE ________ ZIP CODE _________________

HOME PHONE: (_______) _________ - ___________ EMERGENCY PHONE: (_______) _________ - ___________

PLACE NUMBER OF YEARS EXPERIENCE IN BLOCKS	VARSITY	JV	JUNIOR HIGH
T-SHIRT SIZES: UNISEX	MEDIUM	LARGE	X LARGE
ANYONE WISHING TO MAKE FULL PAYMENT MAY DO SO. AFTER JUNE 16, 2010 FULL PAYMENT REQUIRED.
ENCLOSED IS MY CHECK FOR FULL PAYMENT OF:	$485.00 Overnight		$400.00 Commuter
ENCLOSED IS MY CHECK FOR THE DEPOSIT OF:	$200.00 Overnight		$200.00 Commuter
DEPOSITS ARE NON-REFUNDABLE (see PAYMENT POLICY) If you pay only the deposit, the balance due at check-in is: $285.00 FOR OVERNIGHT -OR- $200.00 FOR COMMUTER Make Check Payable to: CAROL MILLER, T.A. Mail Check and this Form to: BLUE HEN FIELD HOCKEY CAMPS, 472 HAYSTACK DRIVE, NEWARK, DE 19711

PART 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 (________) _________ - ________________ RELATIONSHIP: _____________________________________

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; TA 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.

_________________________________________________________, ____________________, 2010
PARENT/GUARDIAN SIGNATURE DATE

POLICIES:THE BLUE HEN ELITE FIELD HOCKEY CAMP, ITS DIRECTOR AND THE DIRECTOR'S ASSISTANT, RESERVE THE RIGHT TO REJECT ANY APPLICATION . THE BLUE HEN ELITE CAMP, ITS DIRECTOR AND THE DIRECTORS ASSISTANT, ALSO RESERVES THE RIGHT TO DISMISS ANYONE FROM CAMP WHO HAS ACTED INAPPROPRIATELY DURING THE CAMP. 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 INFORMED AND TRANSPORTATION IS SECURED. ANY TRAVEL EXPENSES INCURRED ARE THE RESPONSIBILITY OF THE CAMPER AND/OR HER PARENTS.
THE BLUE HEN FIELD HOCKEY CAMPS ARE INDEPENDENTLY RUN AND NOT UNIVERSITY OF DELAWARE PROGRAMS.
PAYMENT POLICY: payment of $200.00 (nonrefundable) must accompany this registration form in order to secure a slot in camp. The balance is due at time of registration ($285.00 for overnight and $200.00 for commuter) . If application is post marked after June 16 full payment is required!
NOTE: Camp will fill on a first come first serve basis. NUMBERS are limited to first 110! Early registrations are strongly encouraged. Without advanced reservations and payment, participation cannot be guaranteed. Commuters will not receive breakfast. There is a $30 charge for all returned checks.
REFUND POLICY: A request for refund must be submitted in writing prior to August 1, 2010. The nonrefundable deposit will be deducted for administrative expenses. NO REFUNDS WILL BE ISSUED UNTIL CAMP HAS ENDED.
FOR INFORMATION: camp2010@bluehenfhcamps.com; Blue Hen Elite Field Hockey Camp, 472 Haystack Drive, Newark, DE 19711302-366-1005; www.bluehenfhcamps.com