Berthoud Athletic Club - Summer Camp Registration Form

Please fill out one form per child. You may select multiple camps per form.

Please note: To select more than one camp per session, please hold down the CTRL key when you click your camp selection. Multiple camps can be selected.

Child's First Name:		Child's Last Name
Child's Age:
Camp Session	Jump Rope 1 (Beginners 1:00) June 23-26 Jump Rope 2 (Advanced 2:00) June 23-26 Jump Rope 3 (Beginners 1:00) July 28-31 Jump Rope 4 (Advanced 2:00) July 28-31 X-cel Sports Conditioning (ages 8-11) July 7, 9, 12 X-cel Sports Conditioning (ages 12-18) July 21-24 Karate Little Dragons July 28-31 Karate Youth July 28-31 Boxing (ages 12-17) July 21-25
Parent/Guardian Contact Information
Parent/Guardian's First Name:		Parent/Guardian's Last Name
Address:
City:
State:
Zip:
Email:
Home Phone:
Work Phone:
Cell Phone:
Emergency Contact Information
Emergency Contact's First Name:		Emergency Contact's Last Name
Home Phone:
Work Phone:
Cell Phone:
Please Select T-Shirt Size
T-Shirt Size:	Small Medium Large Extra Large
$20 Deposit Payment Information
Please note that you must pay a $20 deposit per child to guarantee their Summer Camp Registration. If you choose not to include your credit card inforamtion on this form, you may mail or drop off your deposit payment to Berthoud Athletic Club. Please note that SPACE IS LIMITED – your child's place in camp is not guaranteed until we receive your deposit payment.
Please Choose Payment Method		Check	Credit Card
If you wish to pay by Credit Card, please select:		VISA	MASTERCARD
CC Number:		Expiration Date:
Waiver Agreement
I hereby waive for myself, my heirs, my child, my executors and administrators forever, all claims for damages against Berthoud Athletic Club (BAC), its officers, directors, shareholders, or agents from, or in any way connected with, any and all injuries which may be suffered on or incurred while participating in activities, whether or not authorized by BAC, or by utilizing any of the facilities at its athletic club, or its premises. This waiver shall be applicable even if my injuries arise from the negligence of BAC, its officers, directors, shareholders, employees or agents.
YES, I agree to these terms.