Curry & Powlus QB Camp
Saturday, May 26, 2012
8:30 am to 4:30 pm
Bloomsburg University
 

 
Name (please print clearly)                                                                                                           
 
Address                                                                                                                                      
          
City/State,Zip                                                                                                                              
       
Telephone Number                                                   
        
Grade for Fall of 2012                  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
 
 
 INSURANCE INFORMATION
 
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
 
                                                           
Date