Chesapeake Crew Camps
2009 Application Form
Session Preference: (circle one)
Session I (July 19-23) / Session II (July 26-30)
Full Name: ____________________________
Address (include P.O. and/or Apt. #):
______________________________________
City, State Zip
______________________________________
Phone Number: ________________________
Parent's Email: _________________________
Age (circle one): 13 14 15 16 17 18
T-Shirt Size (circle one): S M L
What is your experience level?
- No experience (novice)
- Beginner (a week or two of experience)
- 1 whole semester/summer of rowing
- 2 whole semesters/summers of rowing
- 3 or more semesters/summers of rowing
- Experienced coxswain
- No experience, but would like to try coxing
Experienced Campers Only -- Name of school/summer rowing program:__
_________________________
In case of emergency during camp contact:
Full Name: ____________________________
Phone Number: ________________________
Payment Information:
- $100.00 check or money order included as deposit (remaining balance due by July 1)
- $575.00 check or money order included as payment in full
Chesapeake Crew Camp for Girls
Insurance and Medical Waiver
Applicant’s Name:_______________________
Medical Treatment Authorization
I/We being the legal guardian(s)
of the above applicant, authorize Chesapeake Crew Camps, LLC and its agents permission to request medical treatment as
necessary to insure the well being of the applicant.
______________________________________
(Parent or Guardian Signature)
Insurance: Coverage for accidental injury is required by all participants. Please complete the health care information
below:
Health Insurance Carrier:_____________________________
Policy Number:_________________________
I approve of my child’s attendance at the Chesapeake Crew Camps, LLC's Chesapeake Crew Camp for Girls/Boys and certify
that (s)he is in good health and able to participate in the program activities.
I (o am / o am not) attaching a statement explaining special physical
limitations and/or required medication. Please indicate if your child suffers from allergies, asthma, diabetes, restricted
activities, etc. In further consideration of the Chesapeake Crew Camps, LLC accepting this application, I/we hereby agree
to save and indemnify and keep harmless the Chesapeake Crew Camps, LLC, its agents, and employees against any and
all liability, claims, judgments or demands for damages arising as a result of injuries sustained by the applicant during
or as a result of any course given the applicant of the Chesapeake Crew Camp for Girls/Boys. I also give permission
for the use of my child's photograph (without identification) to be used for promotional purposes on the website and in printed
documents.
______________________________________
(Parent or Guardian Signature)
Complete this Application and make checks payable to: Chesapeake Crew Camps, LLC and mail both this form and check
to:
Chesapeake Crew Camps, LLC
302 N. Kent St.
Chestertown, MD 21620
