APPLICATION FORM FOR LEANN SHUCK'S CAMP
June 23-26, 2008

NAME______________________________     Please Mail to: Leann Shuck
ADDRESS___________________________     457 Colonial Ridge Lane
_______________________________________  Arnold, Md 21012 
Phone_______________________________Checks payable to LEANN SHUCK GIBBS
School_______________________________
Age____________DOB__________________
E-Mail________________________________
Grade entering fall 2008_____________
Goalie Please Check_________________
Circle the group you will be playing with Spring of 2008
         PEEWEE             MIDGET               JUNIOR       

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 Leann Shuck Lacrosse  Camp and it's 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 Leann Shuck 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 June 23rd 2008.