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APPLICATION FOR DIVING CAMP
MOOSE MOSS AQUATIC CENTER
Moultrie, Georgia
(please print out form and mail to Moss Farms Diving)
1. PERSONAL INFORMATION (please type or print)
Name: _____________________________________________ Phone # (___) ________________
Last First MI (area code) number
Sex: Male____ Female ______ US Diving # _____________ Birthday: ____/____/_____
Home Address: _________________________________________________________________________
City: _________________________ State: _____________ Zip: ________________
Parent(s) or Guardian(s): _____________________________________________
Address (if different from diver): _________________________________________________________
City: _________________________ State: _____________ Zip: ________________
Home Phone: (____)___________ Work: (____)____________ Cell: (____)____________
2. DIVING COACH
Name: _____________________________ Team: ____________________________
Home Phone: (____)__________ Work: (____) ___________ Cell: (____)_____________
Address: _________________________________________________________________________
City: _________________________ State: _____________ Zip: ________________
3. DIVING SESSIONS YOU ARE REQUESTING (check one)
____________ Session 1 - June 15-20, 2008 T-SHIRT SIZE: Adult S M L XL (circle size desired)
____________ Session 2 - July 13-18, 2008
4. APPLICATION AND FEES:
Fees are $525 per session with a non-refundable deposit of $150 due 30 days prior to arrival. Balance is due upon arrival. Failure to pay all fees in advance will result in forfeiture of all deposits and exclusion from the diving facility.
5. DOCUMENTS REQUIRED TO BE SUBMITTED WITH THIS APPLICATION
____ Letter of recommendation and permission to attend camp from your diving coach.
____ Medical insurance card or other proof of medical insurance showing name of company and policy number.
____ Statement of physical condition from physician (M.D.) certifying your physical ability to participate in diving camp activities. Please have your physician list any drug allergies or other unusual conditions affecting your physical condition or your ability to receive medical treatment.
6. CONDITIONS APPLICABLE TO ALL PROSPECTIVE CAMPERS:
A. Moss Farms Diving, Inc. reserves the right to accept or reject any and all applications.
B. Your diving coach must approve your application to attend this camp.
C. You do not and will not engage in the illegal possession and/or use of drugs or alcohol while residing in the Colquitt County, Georgia area during dive camp.
D. You will engage in exemplary, responsible conduct while attending diving camp and while residing in the Colquitt County are. You understand that Moss Farms Diving, Inc. assumes no responsibility for your conduct.
E. You will follow all instructions given to you by Representatives from Moss Farms Diving, Inc. when you are at diving camp and during your stay when we provide lodging.
F. Moss Farms Diving, Inc. reserves the right to immediately dismiss you from diving camp, exclude you from the diving facilities, notify your parents and/or coach, or take other action deemed appropriate by Moss Farms Diving, Inc. should you violate any of the above provisions at the divers expense.
7. SIGNED APPLICATION SHOULD BE RETURNED TO THE FOLLOWING ADDRESS, WITH SUPPORTING DOCUMENTS, ALONG WITH ANY QUESTIONS OR CORRESPONDENCE, TO:
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