Parent / Guardian Information

Name:          Email: 

Address:  
Address:  
City:       State:       Zip:       Country:  

Home Phone:       Work:       Fax:  

Emergency Contact / Medical Information

Name:      Phone: 

Family Doctor:      Phone: 

Camper Allergies / Known Conditions:      Last Tetanus: 

Family Health Insurance Company:      Policy No: 

Camper Information

Name:          Age:  Select Age 6 7 8 9 10 11 12 13 14 15 16 17 18         Gender: Male  Female

Position:  Select One Infielder Outfielder Pitcher Catcher     Camp Date:  Select a Camp Date December 27 - 30, 2008 Residential December 27 - 30, 2008 Commuter

CC #:     Exp Date:     Name as on Card:

Your Application is not considered official until your Application Fee is received by Cocoa Expo.

I understand that the directors and coaches of Cocoa Expo Inc., or anyone associated with Cocoa Expo Sports Center, will not assume responsibility for accidents and medical expenses incurred as a result of participation in this program. The applicant is covered by our family accident and health/dental insurance, is in good health and able to participate in the physical activity of a vigorous program. I hereby authorize the camp directors to act for me according to their best judgement in any emergency requiring medical attention. I will hold harmless the directors and coaches of Cocoa Expo. Inc, and the Cocoa Expo Center of all liabilities, causes of actions, claims and action, claim and demands of every kind and nature whatsoever that may arise in connection either with or resulting from participation in any activities.
Please check that you have read the liability release