WINTHROP UNIVERSITY CAMPER RELEA

WINTHROP UNIVERSITY CAMPER RELEASE FORM

I understand that the tuition to be paid is for the designated dates and covers instruction, insurance (secondary accident and liability), T-Shirt, Ball, and Lunch (Full-day camps). A $75 NON-REFUNDABLE DEPOSIT must accompany this application and the balance must be paid before the camp begins.

I certify that my child is in good health and may participate in all camp activities. In case of an emergency, I grant permission for my child to be given emergency treatment at a local hospital. The undersigned, being a parent or legal guardian of the child requesting camp admittance, does hereby affirm the applicant is physically able to perform activities conducted at the camp and I hereby give my permission for such medical procedures as may be necessary to this camper by Winthrop University in the event of sickness or injury. I understand that, as a condition of admittance as a camper, the undersigned, on behalf of all parents and guardians, and behalf of the applicant, hereby releases Winthrop University and all other employees, volunteers or agents of the camp from any and all liability, from injury, illness, mental or physical, suffered by the camper during or related to camp, to also include transportation and personal property.

Camper's Name _____________________________________________

Parent's or Legal Guardian Signature __________________________________________ Date ______________

Please List All Emergency Contacts

Name _____________________________________ Phone ______________________

Please List Any Medical Information You Feel Is Important

__________________________________________________________________________________________________________

Winthrop University Camp Contacts

Rich Posipanko, Camp Director, 803/323-2129 ext. 6236, posipankor@winthrop.edu

Daniel Ridenhour, Assistant Camp Director, 803/323-2129 ext. 6256, ridenhourd@winthrop.edu

Winthrop University Campus Police, 803/323-3333

Revised Summer 2009