BERNIE KACHINKO'S BOY'S VOLLEYBALL CAMP
BERNIE KACHINKO’S BOY’S VOLLEYBALL CAMP Camp Date: June 26th-29th – King's College Scandlon Gym – 2pm to 6pm Daily For Boy’s entering grades 6th-12th Registration Form: Camper/Team Name: Grade Entering: Parent or Guardian’s Name: Address: City:
State:
Zip Code:
Home Phone Number: Work/Cell Number: Emergency Contact Number: Parent/Guardian Email: T-Shirt Size (Check One):
Small
Medium
Large
XL
I hereby authorize the staff of Bernie Kachinko’s Volleyball Camp to act for me in accordance with their best judgment in any emergency requiring medical attention and I hereby waive and release the camp from any and all liability for injuries or illness incurred while at camp. I have no knowledge of any physical impairment that would be affected by the above camper’s participation in the camp program as outlined. Parent or Guardian’s Signature: Physician’s Name and Number: Special Medical Conditions: Insurance Carrier and Policy Number: EACH APPLICATION MUST BE SIGNED BY A PARENT OR GUARDIAN Enclosed is (Check one): $100 non refundable check: High School Team Rates: (5 or more campers) $70 non refundable check Please make checks payable to Bernie Kachinko Mail to: Bernie Kachinko Head Volleyball Coach King’s College 133 North River Street Wilkes-Barre, PA 18711
State:
Zip Code:
Home Phone Number: Work/Cell Number: Emergency Contact Number: Parent/Guardian Email: T-Shirt Size (Check One):
Small
Medium
Large
XL
I hereby authorize the staff of Bernie Kachinko’s Volleyball Camp to act for me in accordance with their best judgment in any emergency requiring medical attention and I hereby waive and release the camp from any and all liability for injuries or illness incurred while at camp. I have no knowledge of any physical impairment that would be affected by the above camper’s participation in the camp program as outlined. Parent or Guardian’s Signature: Physician’s Name and Number: Special Medical Conditions: Insurance Carrier and Policy Number: EACH APPLICATION MUST BE SIGNED BY A PARENT OR GUARDIAN Enclosed is (Check one): $100 non refundable check: High School Team Rates: (5 or more campers) $70 non refundable check Please make checks payable to Bernie Kachinko Mail to: Bernie Kachinko Head Volleyball Coach King’s College 133 North River Street Wilkes-Barre, PA 18711
