BMXmania.com Pro Training Camp

1311 Sunday Lane

Winona Lake, IN 46590

Phone – (574) 269-5983      Email – Jerry.Landrum@KConline.com

 Camp Registration Form

(If you're ready to register, just copy this registration form to your word processor, print it out and send it to the address above.)

NAME__________________________________________________________________________________

AGE________ DATE OF BIRTH_________ GRADE LAST COMPLETED_________ GENDER________

ADDRESS_______________________________________________________________________________

CITY___________________________________________________ ST__________ ZIP________________

PHONE (_______) _______-___________ PARENT_____________________________________________

EMAIL ADDRESS IF APPLICABLE_________________________________________________________

CLASS (circle one) Rookie – Novice - Intermediate - Girl - Expert   NBL License#_____________

(If you are an ABA member, please contact us and we'll make arrangements for an NBL license.)

Circle One, Please ..... Commuter Camper/$195 – Daily Camper/$75

Medical Authorization/Permission Form

I declare the above named camper to be in good health and permission is granted to participate in all BMX camp activities, unless otherwise indicated on this record. In case of illness and/or injury, permission is granted for medical treatment to be rendered to my son/daughter. I understand that I will be notified in case of serious illness. All medical bills are the responsibility of the camper’s parent or guardian. I also grant permission for any photo or likeness taken at the camp to be used for promotional purposes.

Name of Health Insurance Carrier______________________________ Policy#________________________

Name of Policy Holder____________________________ Name of Employer__________________________

Any specific activities restricted______________________________________________________________

Any special medical or dietary plan to be continued_______________________________________________

Drug Allergies_________________________________  Please be specific____________________________

Please detail special health concerns such as diabetes, epilepsy, sleep walking, bedwetting, recent exposure to communicable diseases, allergies, etc, which would aid us in providing a safe and pleasurable program experience for your child. Please attach additional pages as necessary. ________________________________________________________________________________________

Camper’s Signature __________________________________________________ Date__________________

Parent/Guardian Signature_____________________________________________ Date__________________

  ______Please hold a spot for me at the camp, here’s my $100 registration! The balance will be due upon arrival at the camp.

PLEASE FEEL FREE TO COPY THIS FORM FOR INTERESTED FRIENDS!

Upon receipt of this completed registration form and your deposit, the information and “what to bring” sheets will be sent to you.