Camp Lane Application

Mail application to: 
Dean Dixon, Out West Ent. 
1510 Sylvan 
Eugene, OR 97403
Phone: (541)-683-1715

Name _______________________ 
Address _____________________ 
City ________________________ 
State _________  Zip __________ 
School ______________________ 
Weight ___ Age ___ Grade _____ 
Coach ______________________ 
Day Phone (    ) ______________ 
Night Phone (    ) _____________ 
Family Ins. Co. _______________ 
Policy #_____________________ 
Check
VISA/MC___________________
Expiration date_______________
Amount Enclosed $_________ 
Minimum Deposit         $50.00 
Total Cost        $285.00 

T-Shirt Size (circle one)  S M  L  XL 

I hereby register my child for the Out West Ent. camp and authorize the staff to direct his participation in camp activities.  My child has no medical/emotional problems which may effect his ability to safely participate in your program.  The staff is authorized to attend to any health problem or injury my child may incur while attending camp, including emergency treatment.  I understand that my child must have current medical insurance before he may attend camp.  I authorize the camp to use my child's likeness in any promotional material.  I understand my deposit is non-refundable.  Neither I nor my child hold Out West Ent. staff liable for any injuries or expenses relating to injuries while my child is at camp.  I have read this brochure and agree to all of its terms and conditions.  I agree to pay any damages to property caused by my child. 

__________________________   __________ 
Signature of Parent or Guardian     Date