1. Camper T-Shirt Size (check One)
APPLICATION FORM
CAMPER’S NAME__________________________________________________
Address__________________________________________________________
City_________________________State___________________Zip___________
Phone (_______)__________________________________________________
Grade (entering)______________ Age___________________________________
School___________________________________________________________
Contact Person________________ Daytime Phone (_____)____________________
Address__________________________________________________________________________________________
The 3 day camp will run Tues June 28th -Thurs June 30th PM-8PM
Please make checks payable to: Bishop Hartley Lacrosse Camp
Camper T-Shirt Size (check One)
_____ YM _____ YL _____ YXL _____ XS _____ Small _____ Medium _____ Large _____ X-Large
EMERGENCY MEDICAL FORM
The purpose of this form is to enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under our authority, when parents or guardians cannot be reached.
RESIDENTIAL PARENT OR GUARDIAN_________________________________________________________
Mother’s Name________________________________________________________________________________
Daytime Phone (_______) ______________________________________________________________________
Father’s Name_________________________________________________________________________________
Daytime Phone (_______) ______________________________________________________________________
Name of Relative or Childcare Provider_____________________________________________________________
Relationship___________________________________________________________________________________
Daytime Phone (_______) ______________________________________________________________________
Address______________________________________________________________________________________
I hereby give consent for the following medical care providers and local hospital to be called:
DOCTOR________________________________________ PHONE (_____) _____________________________
In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent of (1) the administration of any treatment deemed necessary by the above-named doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. Facts concerning the child’s medical history, including allergies, medications being taken, and any physical impairments to which a physician should be alerted, I have listed below.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
SIGNATURE OF PARENT / GUARDIAN____________________________________DATE________________

2. ONLY $60! 2016 Tuesday, June 28-Thursday, June 30 5PM-8PM
Columbus, Ohio 43213
1285 Zettler Rd.
Bishop Hartley High School
Bishop Hartley Lacrosse Camp
here
Stamp
Please place
Bishop Hartley Lacrosse Camp
2016
Tuesday, June 28-Thursday, June 30
5PM-8PM
ONLY $60!
@hartleylacrosse
CAMP COSTS
Youth Camp $60
Cost assistance is available in needed.
Please call Molly Gilbert
REGISTRATION
The registration deadline is June 24,2016. After
the deadline please contact Molly Gilbert at or for availability. Campers must pay in full at the time of registration on June 28. To register by mail, complete the camp application and mail Bishop Hartley High School.
DATES/TIMES
Youth Camp
Tuesday, June 28-Thursday, June 30, 2016
5:00pm – 8:00pm
****Registration 4:30pm on Tuesday 6/28
FACILITY
The Lacrosse Camp will be held at Jack Ryan Field on the campus of Bishop Hartley High School
ELIGIBILITY
The Youth Camp is open to any athlete entering
The 3rd thru 8th grades.. This camp is suitable for athletes of all abilities with and emphasis on FUN!
CAMP CONTENT/GOALS
The Youth Camp is designed to introduce the young athlete lacrosse training techniques and skills.
Campers will learn techniques to improve their knowledge and skills in the fastest growing sport on two feet. The goal of the camp is to help student-athletes develop lifelong skills and lessons through the sport of lacrosse.
REFUND POLICY
A full refund, minus a $15 cancellation fee, will be issued for cancellation prior to camp.
No refunds will be given once the camp begins regardless of the reason.
FOR MORE INFORMATION
Contact Molly Gilbert at Or
CHECK THE LACROSSE PAGE AT