Mount Michael Football Summer Camps

Mount Michael Football Summer Camps
Camp Grade Level Dates Cost
Youth 3rd - 6th July 24-26 (9:00 am - 10:30 am) $25 per camper
Middle School 7th - 8th July 24-26 (5:30 pm - 8:30 pm) $25 per camper
High School 9th - 12th July 10, 11, 16-19 (8:15 am - 10:30 am) $40 per camper
Make check payable to Mount Michael Football, fill out this form, put it and your check in
an envelope and mail to:
Mount Michael Football
Attn: Jon Borer
22520 Mount Michael Road
Elkhorn, NE 68022
Camp Sign-up
Name/Grade # for fall 2012
____________________
____________________
____________________
Shirt Size
YM
YL
S
M
L
XL
Shirt Size
YM
YL
S
M
L
XL
Shirt Size
YM
YL
S
M
L
XL
Camps
YTH MS HS
Camps
YTH MS HS
Camps
YTH MS HS
Team/Club or Individual: ______________________________
Phone # _________________ Email: _____________________
Mother’s Name: ________________ cell: _________________
Father’s Name: ________________ cell: _________________
Emergency Contact: ________________ #: _______________

Insurance Information
Camper Name: ______________________________________
Insurance Company Name: _____________________________
Company Address: ___________________________________
Company Phone #: ____________________________________
Policy Number: ______________________________________
I, the undersigned parent or guardian of the above minor, do hereby give permission to the
physician selected by the Director of the Camp to hospitalize, secure proper treatment, and to
order injection, anesthesia or surgery for my child named above. In placing my son in your
care, I agree to all terms, regulations and activities of Mount Michael Team Football Camp. I
agree to bear the burden of any expense arising from accident or illness, which is not cared for
by the camp insurance policy, while my son is under the authorities of the camp. I understand
that the camp fee is nonrefundable in any event. I understand that the purpose of this form is
to totally relieve Mount Michael and its owners, agents and employees from any and all liability
for injuries, deaths, loss of property sustained by me or by my child or by a person in my
charge as a result of participation in a Mount Michael Football Camp activity.
Parent/Guardian Signature: ______________________________
Date: ________________