APPLICATION FORM FOR BAY AREA
July 6-9, 2009

NAME______________________________     Please Mail to: Jim Shuck
ADDRESS___________________________    815 Ritchie Highway Suite 215A
_____________________________________    Severna Park, Md 21146 
Phone____________________________      Checks payable to JIM SHUCK
School______________________________
Age____________DOB_________________
E-Mail_______________________________
Grade entering fall 2009____________
Goalie Please Check________________
    
Circle the group you will be playing with in spring 2010
         PEEWEE             MIDGET               JUNIOR       HIGH SCHOOL

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 Bay Area 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 Bay Area 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 July 6, 2009.