Last Name __________________________ First Name________________________________
Address__________________________________________________________________
City ___________________________________________ State____ Zip____________
Home #(_____) _______ - ______________ Emergency # (_____) _______ - _______________
Age as of July 1, 2010 __________________ Date of Birth ________/________/__________

# of Years playing experience (circle):
Varsity (1 / 2 / 3)     JV (1 / 2 / 3)     Freshman (1 / 2 / 3)     Junior High (1 / 2 / 3)
Grade in School: Fall, 2010 JH_______ FR_______ SO_______ JR_______ SR_______
School Name: Fall, 2010 _______________________________________________
Team Contact Name & # _______________________________(______)______-__________
School Colors: _______________________________

Roommate Request (1) (not guaranteed) Last Name___________First Name___________
Position: Forward______ Midfield________ Back/Sweeper_______ Goalkeeper_______
Shirt size: Small_______ Medium_______ Large_______ X-Large_______ 

Year "2010" ELITE FIELD HOCKEY CAMP WEEKS

Please indicate 1st Choice and 2nd Choice:
Session I: Individual & Team Camp _____ July 11th-14th ($500)
Session II: Individual & Team Camp _____ July 18th-21st ($500) FULL
Session III: Individual & Team Camp _____ July 25th-28th ($500) FULL
Session IV: Individual & Team Camp _____ August 1st-August 4th ($500) FULL

PLEASE SIGN BELOW:
I understand and accept the condition that neither the Elite Field Hockey Camp nor Bentley College will be held liable for accidents and medical and dental expenses incurred as a result of participation in this program. Campers are responsible for property damage and may be sent home without refund for violation of camp rules. In the event of injury or illness, the camp has my permission to provide medical care.

Enclosed please find a $200 deposit. MAKE CHECK PAYABLE TO: Elite Field Hockey. SEND TO: P.O. Box 118, Rowley, MA. 01969. I understand this deposit is non-refundable.

Parent’s Name (Please print name)________________ Parent Signature__________________