Last Name __________________________ First Name________________________________
Address__________________________________________________________________
City ___________________________________________ State____ Zip____________
Home #(_____) _______ - ______________ Emergency # (_____) _______ - _______________
Camper email:_______________________________________________
Age as of July 1, 2012 __________________ Date of Birth ________/________/__________

Playing experience (circle #):
Varsity (1 / 2 / 3)     JV (1 / 2 / 3)     Freshman (1 / 2 / 3)     Junior High (1 / 2 / 3)

Grade Fall, 2012 (circle one) JH  FR  SO  JR  SR
School Name: Fall, 2012 _______________________________________________
Team Contact Name & # _______________________________(______)______-__________
School Colors: _______________________________

Roommate Request (1) (not guaranteed) Last Name___________First Name___________
Position: Field player______ Goalkeeper_______
Shirt size (circle size): Small Medium Large X-Large

Year "2012" ELITE FIELD HOCKEY CAMP WEEKS

Please indicate 1st Choice and 2nd Choice:
Session I: Individual & Team Camp _____ July 8th-11th ($520)
Session II: Individual & Team Camp _____ July 15th-18th ($520)
Session III: Individual & Team Camp _____ July 22nd-25th ($520)
Session IV: Individual & Team Camp _____ July 29th-August 1st ($520) - FULL

VIDEO: (circle)    Yes   No

PAYMENT INFORMATION
A non refundable, non transferable deposit of $200 is due upon registering in order to reserve your place at camp. Prior to submitting your form please read the cancellation policy and refund policy below.
Choose payment:
▢ Pay $200 non refundable non transferable deposit
▢ Pay full camp tuition $520
▢ Add $50 Cancellation Insurance with payment (Full tuition reimbursement if you cancel, minimum of two days prior to start of camp)
▢ Add $40 Video fee

PLEASE SIGN BELOW:
I understand and accept the condition that neither the Elite Field Hockey Camp nor Bentley University will be held liable for accidents and medical and dental expenses incurred as a result of participation in this program. Campers are responsible for property damage and may be sent home without refund for violation of camp rules. In the event of injury or illness, the camp has my permission to provide medical care.