Name: __________________________________________________ 
Email Address: ____________________________________________
Date of Birth:  ________  Age(at camp): ___________    Sex:__________   
Street Address:____________________________________________
City: ___________________________ State: _______ Zip:_________
Home Telephone: (_____)_______________


Parent/Guardian Name: ___________________________
Daytime phone: (_____)______________
Evening Phone: (_____)______________
Parent's Email Address:  _____________________________________

T-shirt (please circle one):  Small    Medium     Large     X-Large
 

Camp Selection:  ___ Navy Stroke Camp
                           

Applications will only be accepted with full payment. 
No deposits accepted.
 

Roommate Request:  _______________________________________

T shirt size:  ___ S  ___ M  ___L  ___XL

PAYMENT
Amount Enclosed: ___________ Check #:___________
Applications will only be accepted with full payment. 
No deposits accepted.



                               MEDICAL INFORMATION
Applicant’s Name:_____________________________

MEDICAL TREATMENT AUTHORIZATION
I/We being the legal guardian(s) of the above applicant, authorize the Navy Swimming Camp 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 email/mail/fax in a copy your current Insurance Card/Information. If, for any reason we need to take your child to the hospital, this will help streamline the administrative process. Please complete the health care information below:
HEALTH INSURANCE CARRIER:_____________________________
POLICY NUMBER:____________________________

I approve of my child’s attendance at the Navy Swimming Camp and certify that he/she is in good health and able to participate in the program activities. I (am/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 Navy Swimming Camp accepting this application, I/we hereby agree to save and indemnify and keep harmless the Navy Swimming Camp, 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 Navy Swimming Camp.
_____________________________________________________
(Parent or Guardian Signature)

Please send a copy of your medical / insurance card at your earliest convenience.
We must have this on file prior to registration.
Copies may be sent to;
Coach Adam Kennedy, Navy Swimming Camp, 628 Cooper RD, Lejeune Hall 4A, Annapolis, MD 21402