Lady Liners Field Hockey Camp

Monday July 8th – Thursday July 11th

(Rain Make-up Day Friday July 12th)

8 am -11 am

Phillipsburg Athletic Complex Turf Field

Belvidere Road

Open to all students entering grades 3-9 for the 2013-2014 school year

Fees: $90 per child

Make checks payable to: Phillipsburg Field Hockey

Camp Fees includes:

- Daily Professional Instruction from Current Varsity Coaching Staff and Captains

- Camp T Shirt

Please send payment with the detached form below to the following address:

Liner Field Hockey Camp: 987 Mill Street, Phillipsburg, NJ 08865

For additional questions:

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Name: ________________________________________________ Grade____________

School_________________________________________________ Age______________

Address_________________________________________________________________

Phone___________________________________________________________________

Emergency Contact/Consent

I give my consent and approval for the above named student to participate in the Lady Liners Field Hockey Camp from July 8- July 11, 2013 (rain date July 12, 2013). I also give my consent and approval for the hospital’s emergency room staff to treat and care for the above named student in the event of an injury/emergency. I am aware that the Town of Phillipsburg, Phillipsburg School District and camp staff are not held responsible for injuries sustained during camp. I further acknowledge that the above named student is of good health and able to participate in the aforementioned camp.

____________________________________ _________________________________

Signature of Parent Guardian Emergency Contact Number

Insurance Yes/No (If yes) Subscriber _____________________________________

Policy Number _____________________________________

Group Number _____________________________________

Any Additional Medical Conditions/Concerns: ______________________________________________

T Shirt Size (Please Circle) Adult Small Adult Medium Adult Large