Curry & Powlus QB Camp
Saturday, May 23, 2015
8:30 am to 4:00 pm
Crispin Field, 1109 N. Mulberry Street, Berwick, PA

Name (please print clearly)                                                                                                            

Telephone Number                                                   
Grade for Fall of 2015                  School                                                                           

Please select a T-Shirt Size (adult sizes only)
        Small                 Medium                  Large                 XL
Please enclose a check or money order for $50 which covers the entire camp tuition, lunch, and camp t-shirt.  Campers are accepted on a first-come, first-served basis.Please mail application, insurance information, and fee to:
Curry QB Camp, Inc., 305 Summerhill Avenue, Berwick PA  18603


Coverage for accidental injury is required by all participants.  In most instances, family health insurance provides adequate coverage.  Please indicate your family health insurance plan below:
         Camp Participant                                                                                     
         Health Insurance Company                                                                       

I/We, being the legal guardian(s) of the participant, authorize C&P QB Camp and its agents, permission to request medical treatment as necessary to insure the well-being of our dependent.

I/We, the undersigned, for ourselves, our heirs, executors, and administrators, waive and release and forever discharge C&P QB Camp, its staff, officers, agents, representatives, employees, successors, and assigns of and from any and all rights and claims for damages to person or property which may be sustained or occur during participation in camp activities, or from camp, whether paid damages, injury, or loss are due to negligence or not.

I/We certify that the participant is in good physical condition, allowing him to participate in the Curry  QB Camp.
                                                                                              Parent/Guardian Signature