| Name | _______________ |
| Social Security # | _______________ |
| Birth Date | _______________ |
| Address | _______________ |
| City | _________ | State |
_________ |
| Zip | _________ | Phone | _________
|
| 98-99
Grade | _________ | Age | _________
|
| T-Shirt Size |
SM M L XL
|
| Gymnastics
Club/School | ________________ |
| Competitive Level | ________________ |
| Coach | ________________ |
| Parents' Name | ________________ |
|
| Resident | $ 325.00 | Parents
Release
for Medical Treatment: I hereby authorize my child's participation in
UIC Gymnastics Camp. I know of no mental or physical problems which
may effect my child's ability to safely participate in this camp. I
hereby authorize the directors and staff to act for me according to
their best judgement in any emergency requiring medical attention.
Neither I nor my daughter will hold the UIC Camp or its staff liable
for any illnesses , injuries, or expenses incurred while at
camp. |
| Commuter | $ 225.00 |
| Early Reg. | -$5.00 |
| Group | -$5.00 |
| Returnee | -$5.00 |
| Total | ________ |
|
| Parent
Signature | _____________________________ |
| Date | __________ |
| |