Northfield, Minnesota, USA

Swim Camp Registration

If you prefer, you may print out and mail a registration
form.

General Information
Camper’s first name:
Camper’s last name:
Address:
City:
State:	AA AE AK AL AP AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY
ZIP:
Parent/guardian name:
E-mail:
Phone:
Roommate requested (one only; roommates must request each other):
Gender:	Female Male
Date of birth (dd/mm/yyyy)
Club or school team:
Grade completed in June 2005:
T-shirt size:	Child size: S M Adult size: S M L XL

Camp selection. Please rank your date preferences in the event your first choice is full.
RANK12345	High Performance	June 12-16	$445
RANK12345	Stroke Technique	June 12-16	$415
RANK12345	High Performance	June 19-23	$445
RANK12345	Stroke Technique	June 19-23	$415
RANK12345	High Performance	June 26-30	$445
RANK12345	Stroke Technique	June 26-30	$415

Emergency Contact Information
Name:
Relationship to camper:
Phone 1:
Phone 2:
Alternative emergency contact:
Name:
Relationship to camper:
Phone 1:
Phone 2:
Please tell us if your child has any medical condition, including possible reactions to prescription medication or allergies that we should be aware of
Insurance provider:
Policy number:
Insurance provider phone:
I have read and agree to the parent waiver.

Fees and Payments			Total
	Camp Fee	Enter fee from schedule above	$
	Family Discount	$20 discount for each sibling when registrations are submitted online on the same day	$-
	Late Registration:	$25 fee for registrations postmarked after May 15	$
		TOTAL REGISTRATION FEES	$

Credit card information
Credit card:	SELECT CARDVisaMasterCardDiscover
Card number (enter numbers only, no spaces or hyphens):
Expiration month:	MONTH010203040506070809101112
Expiration year:	YEAR20042005200620072008200920102011201220132014
Name on card:

Please review all information before submitting.