Central Pennsylvania Intensive Quarterback and Receiver CampCamp Application

Please fill out the following information and mail it to Dr. David Bower 1420 Campbell St., Williamsport, PA. 17701

Camper's Information:

First Name______________________Last Name______________________

Parent/Guardian Full Name____________________ StreetAddress________________________________________ City______________________State _______ Zip________Email______________________________ Phone______________________Date of Birth______________________

Position (Circle One): Quarterback Wide Receiver Tight End Tshirt Size (Circle One) Small Medium Large X-Large

Grade in Fall of 2008 (Circle One): 7th 8th 9th 10th 11th 12th

School Name______________________________ Head Coach______________________________

Camper Type (Circle One):

            1. Resident $275

2. Commuter $250

            3. Two or More Resident Campers from same school $250 4. Two or More Commuter Campers from same school $225

If Resident Camper (reminder each student must fill out their own application)

1. Preferred Roomates Name_______________ Preferred Roomates School_______________

2. Preferred Roomates Name_______________ Preferred Roomates School_______________

Parent/Guardian Emergency Contact Information

Emergency Contact Name ____________________________ Home Phone_______________ Cell or Work Phone_______________

Relationship to Camper (Circle One): Parent Legal Guardian Other:____________________

Medical Release Form

Any restrictions on participation? (Circle One) Yes No if Yes, please explain:___________________________________________

Any Medical allergies? (e.g. penicillin, sulfa, etc.)? (Circle One) Yes No if Yes, please explain: ____________________________

Any Specific Allergies (e.g. certain foods, bee-stings, etc.)? (Circle One) Yes No if Yes, please explain: ______________________

List any prescription medication(s) you will have with you at camp:

1 _____________________________ 2_____________________________ 3_____________________________

Medical Insurance Company ____________________ Group Name ____________________ Policy Number _________________

Effective Coverage Date __________The Policy Holder's Name ____________________

Relationship to Camper ________________

Release Form

My son (or camper) has permission to attend the Central Pa. Intense QB & Rec. Camp. I have no knowledge of any physical

impairment that would affect or be affected by my son’s participation the in the camp activities. In the event of any emergency in whichmy son requires medical care, I authorize the staff of CPI QB & Receiver Camp to act for me and obtain for him whatever medicaltreatment the staff in its best judgment deems necessary and appropriate. I specifically consent to such treatment including, but not limited to hospitalization and surgery and I will be responsible for any medical or other charges in connection with his attendance atcamp. I acknowledge that CPI QB & Receive Camp there is always the risk of an accident, injury or illness. My son will participate inan activity that may include, but not limited to, contact of the body with other persons or objects, including the ground. I specificallywaive and give up and release Central Pa. Intense QB & Rec. Camp, its owner, and staff, from any and all liability for all claims fordamages which I or my son may have for injuries or illnesses that may he may sustain at the Central Pa. Intense QB & ReceiverCamp.           

I authorize Central Pa. Intense QB & Receiver Camp to use any photographs or articles, about my son for publicity purposes. I

understand that violation of camp rules may result in dismissal from camp with all tuition forfeited.

Cancellation/Refund Policy: You must cancel at least two weeks (June 1st, 2007) prior to the beginning of the camp. Cancellation

after June 1st, 2007 will result in a refund of one-half of your total cost of the camp. (See Costs and Discounts)

Camper's Name__________________________ Camper's Signature_______ ______________________Date _____________

Parent/Guardian Name______________________Parent/Guardian Signature___________________________ Date__________

Please mail payment to: Central PA Intense Quarterback and Receiver Camp 1420 Campbell St., Williamsport, PA. 17701

FOR MORE INFORMATION ON THE CAMP PLEASE VISIT WWW.QUARTERBACKDOC.COM