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: *
Address: *
Address Line 2:
City: *
State: *
Zip: *
Country:
Phone Number: *
Parent/Guardian Email Address: *