2004

_____ June 14 -18 _____June 21 - 25

_____June 28 - July 2_____July 12 - 16_____July 19 - 23

_____July 26 - 30_____Aug. 2 - 6_____Aug. 9 -13_____Aug. 16-20_____ Aug. 23-27

Fees: GGTSC Members $350/WAC Members $400/ Non-Members $450
Childcare: $6 per hour
Lunch: $30/week

Name: _______________________________________________________________

Phone___________________Address:____________________________________

City/Zip: ______________________________

Age: ______ Gender:_____DOB:________ Grade: ________ School: ___________________

Please note any medical condition:____________________________________________

Insurance Company:____________________________Policy # ____________________

Doctor's Name and #:_________________________________________________

Emergency Contact:___________________________________________________ 

I hereby authorize the staff of Golden Gateway Tennis and Swim Club to act for me

according to their best judgment in any emergency requiring medical

attention and hereby waive and release GGTSC from any

injuries or illness while at the club. The camp staff has my permission to

seek any emergency treatment necessary for my child while in attendance at

Kids Summer Camp 2004.

Parent/Guardian Signature: __________________________________________Date:_________________

print this form, fill out, with a check in the amount of ______ payable to Golden Gateway Tennis Club/Kids Summer Camp and

send to:

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