Luther

College Triple Option Camp

First Name: _______________________________ Last Name: ________________________________________

Address: _________________________________________________________________________________________

City: _____________________________________________ State: __________ Zip: ________________________

Cell Phone: __________________________________ Home Phone: ___________________________________

Email: ____________________________________________________ Graduation Year: __________________

High School: ____________________________________________________________________________________

Off Position: _____________ Def Position: ____________ GPA: ____________ ACT/SAT: _____________





Insurance Information


I hereby request that you accept the application for enrollment of ________________________
in the Luther College football camp. In consideration of your acceptance of this application, I
hereby release Luther College and all its employees from all claims on account of injuries which
may be sustained by my son while attending the Luther College football team camp; and I agree
to indemnify the consent for medical treatment and permission to the attending physician to
hospitalize, secure proper treatment, and order injections, anesthesia or surgery. I will be
responsible for any medical and other charges in connection with my sons attendance at this
camp. I certify that my son is covered by the medical insurance policy listed below.

Parent/Guardian Name _______________________________________________

Parent/Guardian Signature_____________________________________________
Medical Insurance Company __________________________________________
Policy Number _____________________________________________________
Emergency Contact _________________________________________________
Phone________________________________