ALGONQUIN TRACK & FIELD CAMP

CHOICE OF 2 WEEKS

MONDAY JUNE 14 - FRIDAY JUNE 18

5:00 – 8:00 PM

OR MONDAY JUNE 21 - FRIDAY JUNE 25

 5:00 - 8:00 PM

BOYS & GIRLS

 AGES 6 - 14

 REGISTRATIONS MUST BE RECEIVED BY

MAY 28, 2010

ARHS TRACK & FIELD CAMP

ONE CHILD PER APPLICATION

Parent’s Last Name: ____________________________         Parent’s First Name: __________________________

Mailing Address: ________________________________    City: _______________________  Zip Code: ________

Home Phone: (_____)  ____________ Cell # (______)  _________________  E-Mail address:  _________________________

Athlete’s Last Name: ___________________________          Athlete’s First Name: ___________________________

Date of Birth: _______ -________ -_______                              Gender:  M / F

Choice of week:    1__________    2 _______   T-SHIRT SIZE;  YOUTH      M        L     ADULT   S       M       L        XL  

Cost for week        $95 – 1^st child                      $85 – 2^nd child                      $75 – 3^rd child                      Family Max  -$255

ALL REGISTRATIONS MUST BE RECEIVED BY May 28, 2010

Make checks payable to: Algonquin Track Booster Club

Mail to:  ARHS Track Booster Club

C/O Coach Boschetto

58 Pinehurst Ave.

Auburn, MA. 01501

 Yes _____   No  _____

All groups are set up by date of birth. There will be no changing of groups.

Medical Treatment Authorization

I hereby authorize the staff of Algonquin T& F Camp

to provide medical care that includes routine medical

treatment as necessary to my minor son/daughter.

Signature: _____________________________    Date ___________

Physical conditions that the staff should be aware of

(allergies, recurring illnesses, disabilities, chronic

illnesses, etc.)  ______________________________________________________________________________

Name of family physician: 

______________________________  Phone no.  ______________

Please indicate   HMO       PPO

Insurance company name and address __________________________________

City _____________________________                    State _____                           Zip __________

Policy subscribers name:  ____________________________

Emergency contact name _____________________________              Phone No.: _____________

Camp Staff:                    Andy Boschetto:

Head Track Coach Algonquin H. S.

Defensive Coordinator; Leominster Razorbacks, Semi-pro Football

Certified: Bigger Faster Stronger; Certified Throws Coach

Ken Morin

Sprint, Hurdle, & Relay Coach Algonquin H.S.

Head Soccer Coach - Algonquin H.S.

Certified: Bigger, Faster, Stronger

Ray Lachance

Former Jumps Coach A. R. H. S.

Staff includes track coaches, past and present members of the Algonquin Track team.

ADULTS ARE REQUIRED TO PICK UP CAMPERS ON THE TRACK.