OSWEGO STATE LAKERS ICE HOCKEY SUMMER SCHOOL
APPLICANT INFORMATION
Name:
Date of birth:
Phone:
Cell:
State:
ZIP Code:
Address:
City:
Email Address: (please enter carefully).
Main form of communication will be electronically for these camps.
HOCKEY INFORMATION
circle one:
FORWARD
DEFENSE
Jersey Size Child :
Jersey Size Adult Size:
GOALIE
S/M
S
M
L/XL
L
XL
EMERGENCY CONTACT
Name of a contact while in camp:
Phone:
Cell:
Relationship:
Who besides you may pick up your child?
Relationship:
ALLERGIES/HEALTH CONDITIONS
CAMP SELECTION/ FEES AND PAYMENT (SELECT ALL THAT APPLY)
CAMP
FEE
EARLY BIRD
DUE 5/12
Little Lakers Camp
155
135
SQUIRT ESSENTIAL SKILLS CAMP
300
275
PEEWEE ESSENTIAL SKILLS CAMP
300
275
BANTAM ESSENTIAL SKILLS CAMP
300
275
ALL GIRLS SCHOOL
300
BIRTH YEARS 1999 - 1996 - First Shot Showcase
575
NO EARLY BIRD
BIRTH YEARS 1999 - 1996 - First Shot Showcase Commuter
535
NO EARLY BIRD
BIRTH YEARS 2000 - 2001- First Shot Showcase
575
NO EARLY BIRD
BIRTH YEARS 2000 - 2001 - First Shot Showcase Commuter
535
NO EARLY BIRD
Total
275
Total Due :
Amount Paid: : ($100 non-refundable deposit holds
rate)
st
Balance (due July 1 )
MAIL Registration form, Health History (found on website BELOW) and Payment (PAYABLE TO SUNY OSWEGO) TO:
OSWEGO STATE LAKERS ICE HOCKEY SUMMER SCHOOL
17 MARANO CAMPUS CENTER
SUNY OSWEGO
OSWEGO NY 13126
Online Registration: OSWEGO LAKERS CAMPS ONLINE
Oswego State Athletics
Summer Camp Health Record
And Parental Permission/Hold Harmless Agreement
NOTE: NO CAMPER WILL BE ALLOWED TO PARTICIPATE WITHOUT A COMPLETED HEALTH FORM. Health Form must be
received no later than 10 days prior to camp start date. IT IS ADVISED THAT YOU MAKE A COPY OF THIS FORM FOR YOUR
RECORDS.
Camp(s) Attending:_____________________________________ Session or Camp Date(s): ____________________________________
(one form allows camper to participate in multiple camps, but all camps must be listed)
Camper Name:______________________________________________ DOB:______ / ______ / ______
Gender:
Age:________ Boy Girl
Primary contact:____________________________________________ Relationship: __________________________________________
Day Phone: (______)__________________ Home Phone: (______)___________________ Cell Phone: (______)___________________
Emergency contact:__________________________________________________ Phone: (________)____________________________
I give my child, identified above, permission to participate in the Oswego State Athletics Summer Program (camp or clinic) listed. In
addition, I give permission for my child to go swimming, if applicable, in the Oswego State Laker swimming pool.
______ (initial here if permission is allowed)
I am aware of the inherent dangers and risks involved in summer camps and clinics, swimming and other physical activities
including: bodily injury to the eyes, nose, head neck or back; sprains, fractures, breaks or dislocations of the joints or limbs;
lacerations or concussions.
I understand that Oswego State does not provide any accident or medical insurance for my child. I understand that I am
required to provide accident/medical insurance for my child and do so under the policy provisions listed below. I agree that I am
financially responsible for any and all medical expenses associated with my child’s participation in this program. NOTE: Your child
will not be allowed to participate in our camp(s) unless your medical insurance provider and policy number are provided below:
Insurance Co.:_____________________________________________ Name of Policy Holder:__________________________________
Policy/ID No.:_____________________________________________ Insurance Co. Phone: (________)__________________________
Insurance Co. Address: ___________________________________________________________________________________________
Are there any conditions that limit the child’s ability to participate in all camp related activities? If yes, please give specific details
and limitations below:
Does your child have any allergies we should be aware of? If yes, please list below:
Is your child currently taking any medications? If yes, please list medications and possible side-effects below:
Please list the person(s), other than the parent or guardian, that you child may be released to at the end of each camp session
below:
(OVER)
Medical Treatment Authorization
In the event of an injury or illness, I give permission for my child, ________________________________________________ to be
treated by a qualified athletics trainer, nurse or licensed EMT and/or emergency room staff at the local hospital.
___________________________________________________
(signature of parent or guardian)
__________________________
(date)
I agree that my child must turn in his/her car keys, if applicable, to camp staff at check-in if driving himself/herself to camp.
I agree, on behalf of myself, my child, and our assigns, executors, and heirs, to indemnify, and hold harmless, Oswego State and its
trustees, officers, agents and employees from any and all liability, damage and claims of any nature arising out of or in any way
related to my child’s participation in this program except those things caused by the sole negligence of Oswego State.
___________________________________________________
(parent or guardian please PRINT name here)
__________________________
(date)
______________________________________________________________
(signature of parent or guardian)
A photocopy of your child's Record of Immunizations must be obtained from your physician and submitted on the
physician’s stationary.
PLEASE RETURN ALL FORMS TO:
Oswego State Summer Athletic Camps
SUNY Oswego
Laker Hall
Oswego, NY 13126-3599
Fax: (315) 312-6397