Print Registration

Name:_________________________________________________________

Address:_______________________________________________________

City:__________________________________________ State:___________

Zip:________________ Sex:_______ Grade:________

School:________________________________________________________

Phone #:_______________________________________________________

Email:_________________________________________________________

Emergency Contact:_____________________________________________

Emergency #:___________________________________________________

T-Shirt Size (circle one):

YS              YM              YL              YXL

AS              AM              AL              AXL

Camp Fees:
$50 if received before June 1, 2008
$60 if received after June 1, 2008
$70 if registering on the first day of camp

Checks made to:
South Shore XC Camp
2564 Churchview Dr.
Portage, IN 46368

Waiver:
I hereby give written permission for attendance to the 2008 South Shore Cross Country Camp. All risks attendant to participation in the Camp, including but not limited to bodily injury, are assumed by me or his/her Parent of Legal Guardian as indicated by the signature hereto. In case of injury or medical emergency, I hereby authorize the staff of the South Shore Cross Country Camp to act for me to undertake appropriate medical steps toward the welfare of my child in any emergency requiring medical attention and I hereby waive and release the Camp from any and all liability for any injury or illness incurred while at camp.

Signature:_____________________________________________________ Date:______________
(Parent or Guardian if under 18)