REGISTRATION FORM

__________ July 18-20 Wingate University O-Line Academy

COST: $200 for overnight/$140 for day campers

Name	_____________________________________
Parent/Guardian	_____________________________________
Address	_____________________________________
City/State/Zip	_____________________________________
Home Phone	_____________________________________
Emergency Phone	_____________________________________
School	_____________________________________
Coach	_____________________________________
Grade Next Fall	_____________________________________
Age	_____________________________________

To Be Completed by Parent/Guardian
Medical Insurance Information

Company	_____________________________________
Policy Number	_____________________________________

I/We hereby certify that as the parent/guardian of ________________________,
I/we give permission for the Wingate University Football Staff to seek appropriate
medical attention and for medical attention to be given to him in the event of an accident, injury, or illness on the day of the camp. I will be responsible for any
and all cost of medical treatment, and release the Wingate University staff of any liability.

___________________________________________________
Parent/Guardian Signature							Date

Make all checks payable to Wingate University. Send payment and form to:

        Coach Mike Long
        Wingate University
        Campus Box 3022
        Wingate, NC 28174