2015 Lancer Summer Camps Registration Form

2015 Lancer Summer Camps Registration Form
PLEASE READ & COMPLETE BOTH SIDES OF FORM. ONE FORM PER CHILD.
Student’s name ______________________________________________
Gender M  F
Age ______
Grade Level Fall 2015 __________
Home Address _______________________________________________
City _______________________________ State _____ Zip ___________
School currently attending _____________________________________
Parent/Guardian name(s) ______________________________________
___________________________________________________________
Home phone ________________________________________________
June 8-12
□ English Awesomeness, Coed, Grades 5-8, 8:30-11:30 am
□ Football: 9, Boys, Grade 9, 8:00-11:30 am
□ Boys Soccer: 5-8, Boys, Grades 5-8, 8:30-11:30 am
□ Softball, (Mon-Thurs.), Girls, Grades 6-12, 9:00-11:30 pm
□ Volleyball: 11-12, Girls, Grades 11-12, 8:00-10:00 am
□ Volleyball: 9-10, Girls, Grades 9-10, 10:00 am-12 noon
□ Cookie Camp, Coed, Grade 3-6, 12:30-3:30 pm
□ Rookie Camp: 1-3 & 4-6, Coed, Grades 1-6, 12:30-3:30 pm
□ Boys Soccer: 9, Boys, Grades 9, 12:30-2:30 pm
□ Boys Soccer: 10-12, Boys, Grades 10-12, 2:30-4:30 pm
□ Volleyball: 7-8, Girls, Grades 7-8, 1:00-3:00 pm
□ Volleyball: 3-4 & 5-6, Girls, Grades 3-6, 3:00-5:00 pm
□ Wookie Camp, Coed, Grades 3-6, 12:30-3:30 pm
□ You Pick Two, Coed, Grades 1-2, 12:30-3:30 pm
□ soccer □ gaga ball □ art
June 8-12 TOTAL
Parent Cell phone ____________________________________________
Parent email ________________________________________________
Emergency phone ____________________________________________
Circle T-shirt size YOUTH:
Small
ADULT: Small
Medium
Medium
Large
Large
X-Large
Due to Missouri State High School Activities Association (MSHSAA) requirements
and guidelines, campers who are entering 9th grade must be accepted to
Lutheran South prior to participating in the Lancer Summer Camps. The camps
for 10th-12th grade students are only open to current Lutheran South students.
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Playing with Clay, Coed, Grades 5-8, 8:30-11:30 am
Rockets and Robots, Coed, Grades 5-8, 8:30-11:30 am
Under the Lights, Coed, Grades 5-8, 8:30-11:30 am
Rookie Camp: 1-3 & 4-6, Coed, Grades 1-6, 8:30-11:30 am
Art, Coed, Grades 5-8, 12:30-3:30 pm
Girls Soccer: 5-8, Girls, Grades 5-8, 12:30-3:30 pm
Poms, Girls, Grades 1-8, 12:30-3:30 pm
Rookie Camp: 1-3 & 4-6, Coed, Grades 1-6, 12:30-3:30 pm
Girls Soccer: 9-12, Girls, Grades 9-12, 4:00-6:00 pm
Field Hockey, Girls, Grades 6-9, 6:00-7:30 pm
June 15-19 TOTAL
May 26-28
□ Boys Basketball: 9, Boys, Grade 9, 2:00-4:00 pm
$50
□*Band: 7-9, Coed, Grades 7-9, 4:45-6:00 pm
$65
□ *Band: 6, Coed, Grade 6, 6:15-7:30 pm
$65
□ Girls Basketball: 9-12, Girls, Grades 9-12, 6:00-9:00 pm $60
*Tuesdays, May 26, June 2, 9, 16, 23 and concert on June 24
May 26-28 TOTAL
June 1-5
□ Boys Basketball: 5-6, Boys, Grades 5-6, 8:30-11:30 am
□ Cheerleading, Girls, Grades 1-8, 8:30-11:30 am
□ Football: 3-5, Boys, Grades 3-5, 8:00-9:30 am
□ Football: 6-8, Boys, Grades 6-8, 9:30-11:30 am
□ Hands On Art, Coed, Grades 1-3, 8:30-11:30 am
□ Board Game Extravaganza, Coed, Grades 5-8, 12:30-3:30 pm
□ Boys Basketball: 7-8, Boys, Grades 7-8, 12:30-3:30 pm
□ Behind the Screen, Coed, Grades 5-8, 12:30-3:30 pm
□ Photography, Coed, Grades 5-8; 12:30-3:30 pm
□ Rookie Camp: 1-3 & 4-6, Coed, Grades 1-6, 12:30-3:30 pm
□ Tennis, Coed, Grades 7-12; 5:45-7:15 pm
June 1-5 TOTAL
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$_____
$100
$100
$75
$75
$100
$100
$100
$100
$110
$100
$65
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$_____
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Baseball (Mon-Thurs.), Boys, Grades 5-9, 8:30-11:30 am
Boys Basketball: 1-2, Boys, Grades 1-2, 8:30-10:00 am
Boys Basketball: 3-4, Boys, Grades 3-4, 10:00-11:30 am
Cooks in the Kitchen, Coed, Grades 5-8, 8:30-11:30 am
Hoop Troop: 3-4, Boys, Grades 3-4, 8:30-10:00 am
Hoop Troop: 1-2, Boys, Grades 1-2, 10:00-11:30 am
How Things Tick, Coed, Grades 5-8, 8:30-11:30 am
Boys Basketball Skills, Boys, Grades 5-8, 12:30-3:30 pm
Cookie Camp, Coed, Grades 3-6, 12:30-3:30 pm
Lancer Road Trip, Coed, Grades 6-8, 12:30-3:30 pm
Rookie Camp: 1-3 & 4-6, Coed, Grades 1-6, 12:30-3:30 pm
Wookie Camp, Coed, Grades 3-6, 12:30-3:30 pm
You Pick Two, Coed, Grades 1-2, 12:30-3:30 pm
□ soccer □ gaga ball □ art
June 22-26 TOTAL
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$_____
June 15-19
June 22-26
SELECT YOUR CAMPS:
$100
$100
$100
$65
$60
$75
$100
$100
$75
$75
$75
$75
$100
$100
$110
$100
$100
$100
$110
$100
$100
$100
$75
$50
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$80
$50
$50
$100
$50
$50
$100
$100
$100
$115
$100
$100
$100
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$_____
$_____
July 6-10
□ Girls Basketball: Skills, Girls, Grades 4-8, 8:30-11:30 am
$100 ____
□ Wrestling, Boys, Grades 7-12, 9:00-11:00 am
$75 ____
□ Girls Basketball: Competition, Girls, Grades 4-8, 12:30-3:30 pm $100 ____
July 6-10 TOTAL
July 13-17
□ Science Competition, Coed, Grades 7-8, 2:00-5:00 pm
July 13-17 TOTAL
$_____
$100 ____
$_____
□ I do not require extended care.
□ I would like extended care as specified below.
Early care
7:15-8:20 p.m.
June 1-5
June 8-12
June 15-19
June 22-26
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$20
$20
$20
$20
Late care
3:30-5:30 p.m.
Early and late care
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____ $40
____ $40
____ $40
____ $40
$50
$50
$50
$50
TOTALS
SELECT YOUR EXTENDED CARE OPTION:
Total May 26-28
Total June 1-5
Total June 8-12
Total June 15-19
Total June 22-26
Total June 6-10
Total July 13-17
Total Extended Care
$_____________
$_____________
$_____________
$_____________
$_____________
$_____________
$_____________
$_____________
TOTAL AMOUNT DUE
$_____________
Indemnification and Medical Treatment Authorization
Indemnification by Parent or Guardian of Applicant
Medical Treatment Authorization
The undersigned parent(s) or guardian(s) of
_______________________________________, the applicant for
and in further consideration of the Lutheran South Lancer Summer
Camps accepting said applicant, does hereby release and discharge
the Board of Trustees of the Lutheran High School Association of St.
Louis and its representatives, employees, and agents from any and all
debts, claims, demands, actions, damages, causes of action, judgment,
or suits of any kind which may arise or be occasioned as a result of
the applicant’s participation in the Lancer Summer Camps and hereby
agree to have and indemnify and keep harmless the Board of Trustees
of the Lutheran High School Association of St. Louis, its representatives,
employees, and agents against any and all liability, claims, judgments,
or demands for damages arising as a result of any course instruction
given the applicant by the Lutheran South Lancer Summer Camps. I
further understand that there is no supplemental health insurance
provided by the Lutheran High School Association.
I/We being the parent(s) and/or legal guardian(s) of the applicant
authorize Lutheran High School South and its agents permission to
request emergency medical treatment or care as necessary to insure
the well-being of our dependent. Further, I claim that the registrant
has had a physical examination in the past year and was found fit for all
physical endeavors.
Signature of Parent or Guardian
Date
Signature of Parent or Guardian
Date
Person carrying insurance coverage
Name of Insurance Company
Plan or Policy Number
Please add any information, including medical concerns, that will help us make
the Lancer Summer Camps an outstanding experience for your child:
Deadline:
Photo/Video Release
I represent that I am the parent or guardian of the minor child listed
below and hereby give my consent to Lutheran High School South to
take or use photographs, digital images, and video/audio recordings of
my child for use in printed publications or materials, posters, brochures,
electronic publications, videos or web to promote Lancer Summer
Camps and Lutheran South.
Priority deadline for camp registration is May 15, 2015. All camp
participants who register by May 15 will receive a camp t-shirt. Late
registrations may be accepted, however a t-shirt is not guaranteed.
Return this form with check payable to Lutheran High School South.
Mail or deliver to:
Lutheran High School South
Attn.: Lancer Summer Camps
9515 Tesson Ferry Road, St. Louis, MO 63123
Signature of Parent or Guardian
Questions? Contact the Lancer Summer Camp Director:
Mrs. Debbie Weltmer, 314-833-1067 or dweltmer@lhssstl.org.
Date
Camp details:
All campers should bring a refillable water bottle; refill stations will
be provided. Campers should wear appropriate clothing and bring
equipment as specified in camp descriptions.
Lunch will be provided for students who are attending a morning and
afternoon camp in the same week, or campers may choose to bring a
sack lunch.
9515 Tesson Ferry Rd., St. Louis, MO 63123
314-631-1400 lhssstl.org