Camper's Name:

Mom's Name:

Dad's Name:

Street Address:

City:   State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Not from USA

Zip Code:

E-mail address:

Camper's age: Camper's weight:

Camper's Grade:

Home Phone #:

Cell Phone #: If there's no cell phone is available, enter 0 (zero)

Insurance Company:

Insurance Policy/Grp #: If you don't have insurance, enter "none" in the company and policy/grp# fields.

Make checks payable to AYWA
Enclose $100 NON-REFUNDABLE deposit

Bring your check to the Complex during practice hours (check the calendar page - this will open in a separate window so that your information won't be lost), or mail your check to:

AYWA
P.O. Box 231
Alabaster, AL 35007

Parent/Guardian Authorization: My son has had a recent physical examination and is physically able to participate in all camp activities and is free from infectious diseases. I relieve the Camp Jacob Directors and AYWA of any responsibilities should any accidents occur. I give my consent for the AYWA Staff to seek treatment and transport should my son become injured. I understand this wrestling camp is a strenuous and physical activity and serious injury may result in camp participation. I certify to the best of my knowledge that my child is in good physical condition and has no disease that would impair his performance in training or competition. I also understand I will receive the Camp Jacob Itinerary upon receipt of application and that my balance is due on the day of check-in (May 31).

Camper Signature:
Date:

By entering/typing in your name, you are officially signing this form. If you'd rather sign a 'hard' copy later, enter "No Sign" in the "Camper Signature" field.

Parent Signature:
Date:

By entering/typing in your name, you are officially signing this form. If you'd rather sign a 'hard' copy later, enter "No Sign" in the "Parent Signature" field.

Note: Concessions will be available and commuters may purchase lunch tickets (3) for $20

Please select ONE:
Resident Camper: $225 (includes lodging and meals)
Commuter Camper: $150
Resident Coach: $150 (includes lodging and meals)
Commuter Coach: $75

If you are a commuter, would you like to purchase 3 Lunch Tickets for $20?  
Yes
No

Please select your T-shirt size:  
Youth Small   Youth Medium   Youth Large  
Adult Small   Adult Medium   Adult Large  
Adult X-Large   Adult XX-Large