CENTROWITZ RUNNING CAMP REGISTRATION

CENTROWITZ RUNNING CAMP REGISTRATION
Secure Payment Form

Registration Information:

Camper First Name:

Camper Last Name:

Address:

Address Line 2:

City:

State:

Zip:

Country:

Phone Number:

Mobile Number:

Camper Email Address:

Date of Birth:

Gender:*

MaleFemale

T-Shirt Size:

SmallMediumLargeXLargeXXLarge

Dietary Restrictions:

School/Club Name:

Repeat Camper:

YesNo

Referred By:

Waiver:*

In case of injury or medical emergency, I hereby authorize the staff of Centrowitz Running Camp to act on my behalf according to their best judgment. I hereby waive and release Centrowitz Running Camp, Portsmouth Abbey School, and their principals, staff, and guests from any liability for any injury or illness incurred while at camp.

I agree to the above waiver.

Photo Release:*

I give permission for photographs/videos taken of me/mychild/ward while participating in Centrowitz Running Camp to be used in marketing/public relations material in the promotion of Centrowitz Running Camp.

I agree to the above photo release.

Credit Card Information:

Card Type:

Name as on Card:

Card Billing Address:

Card Billing Zipcode:

Card Number:

Card Expiration Date:

(MMYY)*

Card ID (CVV2/CID) Number:
[What is the Card ID?]

Billing Information:

Payment Amount:

Company Name:

First Name:

Last Name: