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                                        CLIFF ROBINSON SUMMER

                                    BASKETBALL CAMP APPLICATION

Name___________________________________________________________________________

Height____ Weight _______ Age____

Address___________________________________________________________________________

City___________________________________________________________________________

Phone__________________________________ Home__________________________________________

Father's Work No.___________________________________________________________________________

Mother's Work No.___________________________________________________________________________

Emergency Contact___________________________________________________________________________

Emergency Phone No.___________________________________________________________________________

Medical Insurance Company___________________________________________________________________________

Policy No.___________________________________________________________________________

Roommate request___________________________________________________________________________

St.__________ Zip -____________

Please check appropriate box:

__ June 21 - June 26/ Resident ($150.00 Deposit)

___June 21 - June 26 / Extended Day ($125.00 Deposit)

___June 21 - June 26/ Day ($100.00 Deposit)

Make checks payable to and mail to:

Terry O'Connor
5 Breton Woods Road
Trumbull, CT 06611

WAIVER AND RELEASE: I understand that any camper who does not abide by the rules and regulations promulgated by the camp is subject to dismissal without reimbursement or recourse. No camper will be allowed to leave the camp grounds for any reason other than a medical emergency until the completion of each camp session.

 

INSURANCE WAIVER: I hereby authorize the Director of the Cliff Robinson  Camp to act for me according to his/her best Judgement in any emergency requiring medical attention. I hereby release and discharge the Cheshire Academy school, the Camp staff, Terry O'Connor, Jim O'Connor, Cliff Robinson, and affiliated entities and their officers, agents and employees from and against any and all liability or causes of actions arising out of or in connection with my participation in the Camp.

Camper Signature_______________________________________________________________________

Parent/Guardian Signature________________________________________________________________