UNITED STATES SPORTS CAMPS

2010 Registration Form (Please Print in Black Ink)

 

Name  ______________________________ Birth date _________ Age At Camp_______  Gender:     □ Male   □ Female

 

Street Address  _____________________________________________  City  _________________________________

 

State  ____ Zip Code  _________Phone (_____)__________________Email Address____________________________

Name of Your Coach (_____)_________________________________________________________________________

 

Your Coach’s Address  (Street)  _______________________________________  City ___________________________

 

State  _____ Zip Code  _________Phone  ________________________Email Address___________________________

 

Name of Roommate Desired  _____________________________________________________   Check if Commuter □

 

Referred by  ______________________________________________________________________________________

 

WE RECOMMEND THAT YOU KEEP A COPY OF THIS APPLICATION FOR LATER REFERENCE.

 

CAMP LOCATION REQUEST        PLEASE CHECK YOUR CHOICE (s)

 

CAMP LOCATION          2010 Date         2010 Fee           Deposit w/         Balance due

(Check weeks)                                                                 application        by 6/1/10
Mount Holyoke College

□  South Hadley , Mass  June 27-July 2    $785.00             $200.00             $585.00

□  Weekend stayover*     July 2-4             $250.00                Payable with balance

□  South Hadley , Mass  July 4-9             $785.00             $200.00             $585.00    

□  Weekend stayover*     July 9-11           $250.00                Payable with balance

□  South Hadley , Mass  July 11-16          $785.00             $200.00             $585.00

 

*Weekend stay over is only available with two week registration.

If paying by check, please make checks payable to: U. S. Sports Camps, Ltd. or (U.S.S.C.)

 

Circle Your Credit Card:    MC   VISA  

Amount charged on card - please check:  ❏ deposit    ❏ balance on 6/1/10    ❏ entire amount upon receipt of application

 

Credit Card Number____________________________________        Card Expiration Date____________

 

Name On Card_________________________________________

 

mail payment/completed application to:   U. S. Sports Camps, Ltd.  •  P.O. Box 428  •  Earlysville, VA 22936

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U. S. Sports Camps has my permission to have  ______________________________________________  (Name of Applicant)

 

treated professionally in an emergency.  Parent/Guardian Signature  ______________________________________________

Parents/Guardians: We need original signatures on all applications - no faxes, copies or emails

 

Campers must have their own health insurance.

 

Name of Insurance Carrier  (MUST BE FILLED OUT)  ________________________________________________________

 

Policy Number  _________________________________________________________________(No insurance, No camp)

 

All deposits of accepted applications are non-refundalbe. All cancellations after June 1, 2010 are non-refundable.

USSC accepts MasterCard, Visa, credit cards for deposits and balance of payment.