Mountain Bike Camp Summer 2006

Application to Camp

Name (First and Last) (in ukrainian):_____________________________________________
Name (First and Last) (in English) :______________________________________________
Address:__________________________________________________________________
Telephone:________________________________________________________________
email address:________________________________________________________________
Birthdate _______________________  Religion________________ SSN_______________
Plast Oseredok (Stanytsya)__________________________ Kurin'_____________________
Yunatskyj Stupin'______________________________Number of camps attended:_________
Name of Parent or guardian (in English)____________________________________________
Telephone1  who's?___________________  number_________________________________
Telephone2  who's?___________________  number_________________________________

I give permission for my son/daughter to attend and participate in the Burlaky Mountain Bike Camp.
Parent/guardian signature: __________________________________Date:_________________
I agree that __________________________ should attend and participate in the Burlaky Mountain Bike Camp.
Signature of zviaskovyj/va: __________________________________Date:_________________
Please send this application and full payment ( total cost for camp is $365 US) for the camp no later than June 1, 2006 to:

Petro Kowcz
17410 Lake Ave
Lakewood, OH 44107
(216) 469 9040

After June 1, the cost is $395

Additional Information:

Bike:  Make:______________________
        Model:_______________________
        # gears:______________________

Level of expertise:   beginner____________  intermediate____________ expert_____________

General Treatment Consent

This is my consent to initiate and proceed with all methods of study, diagnosis and treatment which, in the physicians judgement, are indicate for the camper's welfare. In the even the camper's condition requires prompt emergency treatment to save the life or preserve the health of the camper, I hereby give my permission for such medical and surgical treatment, as well as anesthesia.

Signature:________________________________ Date:_______________
Relation to Camper:____________________________________________