Summer Camp Application

Make checks payable to Robert E. Johnson and mail with Medical and Immunization Forms to:

The Track and Field Academy at Brown
Brown University
Box 1932
Providence, RI 02912

Name: _______________________________________________

Parents' Names: _____________________________________

Address: ____________________________________________

City: _______________________________________________

State: _________________ Zip Code: __________________

Age: ______________ Date of Birth: __________________

Male: ___ Female: ___ T-Shirt Size: M - L - XL - XXL

Home Phone Number: __________________________________

Emergency Phone Number: _____________________________

School: _____________________________________________

Event: (please circle)
Throws: Shot Discus Javelin Hammer
Hurdles: High Intermediate
Sprints: 100 200 400
Jumps: HJ LJ TJ

Please check financial arrangement:
_____ $410 - resident ($100 deposit)
_____ $170 - commuter ($50 deposit)
Deposit is non-refundable

Waiver and Release

*PARENTS PLEASE READ AND SIGN*
I hereby approve my child's attendance to The Track and Field Academy at Brown University, and certify that he/she is in good health and able to participate in the program activity and authorize the director to act for me according to his best judgement in any emergency requiring medical attention for which I will pay.
Signature:________________________________ Date:___________________