Philadelphia Scholastic Officials Camp
LaSalle University, Tom Gola Arena
June 8 - 10, 2007

Application Form

PLEASE NOTE:
WE DO NOT PROVIDE HEALTH AND
ACCIDENT INSURANCE
You are required to have your own Health/Accident Insurance.
REMEMBER CAMP SPACE IS LIMITED
SO SIGN UP TODAY!


FULL NAME:   EMAIL:
ADDRESS:
CITY: STATE:        ZIP: 
HOME PHONE: WORK PHONE:
CELL PHONE: SHIRT SIZE: M   L   XL   2XL
MEDICAL INSURANCE:
COMMENTS:

TOTAL COST $150

enclosed is a check for my $100.00 non-refundable deposit    enclosed is my full payment of $150.00
Make checks payable to:   Philadelphia Scholastic Officials Camp
  c/o Jim King
  2818 Maxwell Street
  Philadelphia, PA 19136
For further information please contact: Mike Chesney, 856-308-2056 or Jim King, 215-969-0946