MID-STATES SWIM CAMPS
REGISTRATION FORM 2008
Name
_________________________________
100-Free Time ________________
Address
_______________________________________________________________
Phone
( ) ______________ Birth Date
____________ Age _____ Sex _____
Parents’ or Guardians’ Names
_____________________________________________
E-Mail
_________________________________
T-Shirt Size (circle) S M L XL
(adult sizes)
Roommate
Choice ________________________________________________________
Insurance Company
_________________________ Policy No.
__________________________
q June 8-12 St. Mary’s University (
q June 15-19 St. Mary’s University (
q June 15-19 St. Mary’s University (
q June 22-26
q July 6-10
q August 3-7
(
q August 3-7
(
q
I attended Mid-States Swim Camps last year.
q
I would like to be in the Special
Training Group at St. Mary’s University on June 15-19.
My
second choice campsite, if first is filled, is
_________________________________.
Date
___________________
Deposit
is non-refundable and non-transferable and must accompany this
registration. Balance is due 30 days before the camps are scheduled.
Deposit
is $100 per session, payable to: MID-STATES SWIM CAMPS
Call
(262) 334-1213 if you have any questions or concerns.
Fax
No: (262) 334-1228 E-mail: midsts@nconnect.net Web Page: www.nconnect.net/~midsts
CANCELLATIONS: Full payment cancellations must be received
in writing at least 30 days prior to the enrollment date. All cancellations are
subject to a $50.00 service charge.
Do
Not Detach – For office Use Only
Date
Rec’d ____________ Date Conf’d ____________
Date Ent ____________
Deposit:
Am’t Rec’d ____________ Ck. No.
____________ Ck. Date ____________
Balance
Due ____________
Balance
Due:
Am’t Rec’d _________ Date Rec’d
_________ Ck. Date _______ Ck. No.
_______