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Athletic Camp Base Registration

Forms

Required

Name of 1st Participantrequired
First Name
Last Name
T-Shirt Size 1st Participantrequired
Youth T-Shirt Size 1st Participantrequired
Adult T-Shirt Size 1st Participantrequired
Parent or Guardian's Name:required
First Name
Last Name
Anyone other than a parent or guardian authorized to pick up the participant(s)?required
1st Participant's Health Restrictionsrequired
Is 1st participant carrying an EPI pen or other medical device.required
If yes, is the 1st participant trained in the self-administration of their Inhaler or EPI Pen?required
Is the 1st Participant Covered by Health Insurance?
Participant Health Insurance - include company group/ID number

1st Participant
In the event a child is not covered under medical insurance, Misericordia University requires that parents/guardians agree to incur the cost of medical expenses of their child. By clicking yes, the parents/guardians agrees to be financially responsible for all medical costs incurred by my child at this Summer Sports Camp.  A Note to Parents/Guardians without Medical Insurance: You MUST click where indicated if you carry no medical insurance on the child. Those who do not assume financial liability for medical costs will not be allowed to register.

Agreementrequired
$175.00
Register 2nd participant from same household?required
Name of Second Participantrequired
First Name
Last Name
T-Shirt Size 2nd Participantrequired
Youth T-Shirt Size 2nd Participantrequired
Adult T-Shirt Size 2nd Participantrequired
2nd Participant's Health Restrictions required
Carrying an EPI pen or other medical device 2nd Participant.required
If yes, is the2nd participant trained in the self-administration of their Inhaler or EPI Pen?required
Is the 2nd Participant Covered by Health Insurance?
Participant Health Insurance - include company group/ID number

2nd Participant
In the event a child is not covered under medical insurance, Misericordia University requires that parents/guardians agree to incur the cost of medical expenses of their child. By clicking yes, the parents/guardians agrees to be financially responsible for all medical costs incurred by my child at this Summer Sports Camp.  A Note to Parents/Guardians without Medical Insurance: You MUST click where indicated if you carry no medical insurance on the child. Those who do not assume financial liability for medical costs will not be allowed to register.

Agreementrequired

Releases and Code of Conduct for all Participants.

Misericordia University routinely promotes programs and activities involving minors through various media. This includes, but is not limited to newsletters, newspapers, brochures, and displays. In doing so, the names and photos of members may be included to help tell the story.
Please select any that apply.requiredPlease select up to 2 choices
Please select up to 2 choices
By Checking the Box Below I Verify that Have Read and Agree to the Youth Program Code of Conduct for all Participantsrequired
Release and Medical Consentrequired

Payment Information

Please complete captcha below to proceed to payment selection.

Please select a payment typerequired
Billing Addressrequired
Cardholder Namerequired
Expirationrequired
<p>Submit Payment to:<br /> Misericordia University<br /> Attn: Athletics/ Camp Name<br /> 301 Lake Street<br /> Dallas, Pennsylvania 18612</p>