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Print and return with a check payable to:

MIKE SMALL, INC.
1716 LARCH DR.
MT. PROSPECT, IL 60056

NAME_________________________________________PHONE__________________

ADDRESS__________________________CITY__________________ZIP__________

SCHOOL___________________________GRADE (AS OF DATE OF CAMP)_________

AGE AS OF 1/1/14 (FOR HOTSHOT CONTEST)______________

BOY____GIRL_____EMAIL____________________________

Cost is $95.00 per camp registration.

YOUR CANCELED CHECK IS YOUR CONFIRMATION (Save Trees!!)

Please indicate the camps you wish to attend and mail early as class size is limited!

CAMP #________________ LOCATION________________________

CAMP #________________ LOCATION________________________

CAMP #________________ LOCATION________________________

Total check enclosed: $________________

Check T-shirt Size: Youth Small_______ Youth Medium_______ Youth Large_______
Adult Small_______ Adult Medium_______
Adult Large_______ Adult X-Large_______

I hereby authorize the staff of the camps listed in this brochure to act for me according to their best judgement in any emergency requiring medical attention and I hereby waive and release Mike Small Inc., staff, the camps listed, and locations from any injuries or illnesses incurred while at camp. I have no knowlege of any physical impairment that would be affected by the above camper's participation in the camp program.

Parents' Signature _____________________________ Date____________
Emergency Phone Number_________________________Contact:__________________

REMEMBER TO REGISTER EARLY AS ALL CAMPS ARE LIMITED! WE GIVE INDIVIDUALIZED ATTENTION TO EACH PARTICIPANT!


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