OFFENSIVE/DEFENSIVE LINE CAMP
AND PERIMETER CAMP
June 17-19, 2016
LAST DAY TO REGISTER: JUNE 13, 2016
Circle One:
Resident
Commuter
Name: _________________________________________________________________________
First
Last
MI
Address: _________________________________ City__________________ ST____ ZIP ______
Parent/Emergency Contact: _____________________________ Phone#______________________
Email: _____________________________________ Height ____ Weight ____ Age: ____ Sex:____
Football Position for Padded Camp:
Position: _________________________ Alternate Position (if desired) ___________________
Grade Entering in fall 2016:___________ School: _________________________
Adult T-Shirt Size S
M
L
XL
XXL (Circle one)
Roommate Preference: __________________________ (List one only)
Enclosed is __________ $275(Resident)
___________$210 (Commuter) (meals included)
Pad Rental: ___________ $40 Mouth Guard __________ $2
Physician Name & Phone #:______________________ Insurance Co. ___________________
Policy Number: _____________________
List any Medications taken regularly: _______________________________________________
List any Medical Issues: ___________________________________________________________
(Allergies, medications, insect bites, Asthma, Diabetes, etc.)
Participants must have had a physical exam with 36 months of the camp to participate. Date of Physical: ____________
I verify that my son/daughter has been checked by a licensed physician and is physically able to participate in this Sports Camp/Clinic. I agree to
allow my son/daughter to be treated by a licensed physician while attending, if necessary, and to assume all costs related to such treatment. I
authorize my insurance company to pay benefits. Also, I authorize the disclosure of medical information to my insurance company for the
purpose of a claim. I understand that if this application is accepted, there is no refund of the deposit if we (parent or son/daughter) should
cancel the application later.
The undersigned does hereby agree to hold harmless and indemnify the State of Wisconsin, the Board of Regents of the University of Wisconsin
System, and the University of Wisconsin Oshkosh, their officers, agents and employees, from any and all liability, loss, damages, costs, or
expenses which are sustained, incurred, or required arising out of the actions of my son/daughter in the course of the camp/clinic.
Participant Name: ______________________________________ Parent / Guardian Signature_____________________________________
PLEASE PRINT
Parent/ Guardian Name – PLEASE PRINT: _________________________ Date: __________________
Mail form to: UW Oshkosh Sport Camps
800 Algoma Blvd.
Kolf Sports Center
Oshkosh, WI 54901