Please COMPLETELY fill out this form andreturn it to LHS by June 21st, 2013 with payment of $60. Late registration cost is $70.Checks made payable: Liberty CC Atten: Doron WhiteLiberty High School6300 Independence Ave.Bealeton, VA 22712
Parent/Legal GuardianStreet AddressCity/State/Zip CodeE-mail AddressDaytime Phone Evening PhoneCurrent School (2012-2013) Grade FinishedEmergency Contact Phone
6300 Independence Ave.Bealeton, VA firstname.lastname@example.org
Liberty High SchoolCC/T&F Presents:
I recognize the possibility of physical injury associated withthis summer camp. I understand that the Liberty Staff and/orany-one associated with the track & field camp will not assumeresponsibility for any loss, liability, damage, medical or dentalcost or any other expenses incurred as a result of any injuryand/or property damage that the above named camper maycause or sustain while participating in this summer camp.