Connecticut Field Hockey Camp Registration Phone: 888-594-2315 To enroll, print this form. Complete and return along with a check for a deposit of $150.00 made payable to the Connecticut Field Hockey Camp. Total fee is $495 for Team registration (10 or more) and $505 for Individual registration. Form will not be accepted without deposit and signatures. Mail to:    Connecticut Field Hockey Camp, LLC    P.O. Box 728    Storrs, CT 06268 Check the camp session you are registering for: _____ July 11-14, 2009   _____July 16-19, 2009   _____July 22-25, 2009 Please Print: Name of Camper:  _________________________________________________________ Name of Parent/Guardian:  __________________________________________________ Mailing Address  _______________________________________________ City ________________________   State _________  Zip _______________ Phone: ___________________________________ Email address (parent/guardian): ________________________________________ High School _____________________   Coach: _______________________ Grade entering in fall 2009 ______   Roommate  _________________________                                                   please list only one roommate; there are NO triples! Position:  Field Player _________ or Goalie _________ (check only one) Years of Experience:  ____Varsity   ____Junior Varsity   ____Junior High/Middle School Waiver Statements All campers must have their own medical coverage. The Camp provides only excess coverage after your insurance policy has been utilized. Campers will not be allowed to play unless the following information is submitted and the form signed by the parent or guardian of the camper. PLEASE PRINT THIS IMPORTANT INSURANCE INFORMATION CLEARLY Camper's Insurance Company  ______________________________________________  Policy Number  ______________________________________________ I/We the undersigned, hereby certify that I (we) am (are) the parent or legal guardian of the camper. I hereby give permission for the staff of the Camp to seek during the period of the Camp appropriate medical attention to be given and for the camper to receive medical attention in the event of accident, injury or illness. I will be responsible for any and all costs of medical coverage policy. I/We the undersigned, for ourselves, our heirs, executors and administrators, waive, release and forever discharge Connecticut Field Hockey Camp, LLC and its staff, officers, agents, employees, representatives, successors and assign of and from all rights and claims for damages, injury or loss to person or property which may be sustained or occur during participation in Camp activities or while at Camp, whether or not damages, injury, or loss is due to negligence. I/We the undersigned fully understand that the University of Connecticut will not be held liable for any occurrence at camp.   _________________ Date _________________________________________ Camper's Signature   _________________ Date _________________________________________ Parent's Signature