APPLICATION FORM FOR DELMARVA
TBA

NAME______________________________ Please Mail to: DelMarva Camp
ADDRESS___________________________     457 Colonial Ridge Lane
_______________________________________      Arnold, Md 21012
Phone__________________________Checks payable to Jennifer Baldwin
School_______________________________
Age____________DOB________________
Grade entering fall 2009_____________
Goalie Please Check_________________
E-Mail ______________________________   
Emergency Phone______________________________________
Insurance Form
Cover for accident injury is required by participant.  In most instances Family Health Insurance is adequate.  Please indicate your family Health Plan below.
Health Insurance Carrier:

______________________________
Policy Number:

_____________________________
Waiver and Release
I being the legal guardian of the applicant authorize Delmarva Girls Lacrosse  Camp and it agents to request medical treatment as necessary to insure the well being of my daughter.  I further certify that my daughter has had a physical exam with in the past year, is in good physical health and may participate in all camp activities.
I hereby release Delmarva Girls Lacrosse Camp, it successors, assigns, officers, camp instructors, and employees for any and all claims resulting from participation in the camp.
Date_______________________
Parent/Guardian Signature_____________________________

Fee $140.00 Full payment or non-refundable payment of $40.00 should be mailed with application.  Balance of fee is due on TBA.