Name Address

City State    Zip   Phone    Age

Email Address Grade you will be in September 2011

Shirt Size  Small Shirt Medium Shirt Large Shirt Extra Large T-Shirt Sizes   

Camp(s) You Want To Attend:

Session I (June 27-July 1)  
Session II (July 11-15)  
Session III (July 25-29)
Session IV (Aug 1-5)
 

Cost is $110.00 per Session.  If your child attends additional sessions the cost is $100 per week.

Parental Permission & Medical Release Form:  I request that you accept the application of my son/daughter for the 2011 camp at Loyalsock.  I hereby release Loyalsock School District and the Ron Insinger (CI) Basketball Camp from all claims due to any injuries, medical, dental or any other loss of personal property.  My son/daughter is covered by a personal insurance policy, or is included in my program.  I hereby authorize routine medical care for my child and I authorize treatment not considered routine to be referred to local physicians at my expense.

Parent's Name    Date

By typing your name above you are agreeing to register your son/daughter to camp.

Registration: Please send a check for $50.00 as a nonrefundable deposit made out to Ron Insinger.  The remaining $60.00 can be paid at registration on the first day of camp.  No confirmations will be sent out.  For more information contact Ron Insinger at 570-326-3581 (W) or 570-337-0676 (C).

Please send your payment to:

Ron Insinger
Loyalsock High School
1801 Loyalsock Drive
Williamsport, PA 17701