1 - Print This Web Page From Your Web Browser and Complete the Application

2 - A Parent Must Sign The Release At The Bottom Of The Application

3 - A Photocopy Of The Student’s Health Insurance Card Must Be Sent With This Application

4 - Mail The Printed Application With A $100 Non-Refundable Deposit Or Full Payment

     Made Out To “MOUNTAIN HIGH RUNNING CAMP, LLC” and Mail To:

     Scott Simmons, Mountain High Running Camp,

     1900 Selwyn Ave, Charlotte, NC 28274

5 - Full Payment Is Due At Check In - Cash Only, No Checks Or Credit Cards At That Time!

Select One:            ____    Individual Camper July 11-16th ($475)

                                 ____    Camper With Team of Seven  ($465)

                                 ____    Coach or Parent ($375)

                                 ____    Coach With Team of Seven (FREE)

SEX:    ____ Male        ____ Female        ____ Male Coach        ____ Female Coach

Name: ___________________________________________________________________________________

Shoe Size: ** Campers will receive an $75 gift certificate at Running Warehouse.com plus a discount code to purchase most shoes online. If you desire shoes that exceed the credit and discount, you must pay the difference. RunningWarehouse.com offers free returns on all shoes!

Address / City / State / Zip Code: ___________________________________________________________

Your Email Address (Print Clearly!): _______________________________________________________

Parent’s Email Address:  __________________________________________________________________

Home Phone Number: ____________________________________________________________________

School: __________________________________________________________________________________

Birthdate: _______________________________________________________________________________

Year In School Spring 2010 (Fresh, Soph, Junior, Senior): ____________________________________

Coach's Name:  __________________________________________________________________________

Coach's Email:  __________________________________________________________________________

Coach's Phone:  __________________________________________________________________________

Best Mile Time:  __________________________________________________________________________

Best 2-Mile Time:  ________________________________________________________________________

Average Number of Miles Per Week: _______________________________________________________

Roommate Request: ______________________________________________________________________

Parent's Name:  __________________________________________________________________________

Parent's Cell Phone And Home Phone:  _____________________________________________________

Will You Need Airport Pickup? (if so, email details to coach@mountainhighrunning.com)

_____________________________________________________________________________________

** YOU MUST SEND PROOF OF MEDICAL INSURANCE WITH APPLICATION!

(A photocopy of the front and back of the campers medical insurance card is required)

Campers are responsible for any and all medical expenses incurred at camp!

Please do not bring valuables, electronics or large sums of money. The camp will not be responsible for lost or stolen items.

IF ASTHMATIC OR ALLERGIC TO BEE STINGS, YOU MUST BRING A BEE STING KIT AND/OR INHALER!!

PARENT/GUARDIAN AUTHORIZATION.

I hereby give permission to the physician selected by the Mountain High Running Camp staff to order X-rays, routine tests and treatment for the health of my child. In the event I cannot be reached in an emergency, I hereby give permission to the attending physician to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child. I understand that Mountain High Running Camp and its staff, and Lees-McRae College and its staff are not liable for any medical charges. Campers are responsible for any and all medical expenses incurred during camp. If allergic to bee stings, my child must bring a bee sting kit.

In addition, I acknowledge that distance training is a potentially hazardous activity and that I have made a voluntary choice to permit my minor child to participate in the Mountain High Running Camp despite the risks that it presents. I agree to ASSUME ANY AND ALL RISKS OF INJURY OR DEATH which may be associated with or result from my minor's participation in this event.

I further agree to RELEASE FROM LIABILITY and to INDEMNIFY AND HOLD HARMLESS Mountain High Running Camp and its staff, and Lees-McRae College and its staff for damage, injury or death to the participant or to any person or property (whether or not caused by their NEGLIGENCE) in any way connected with the participant's preparation, or practice or participation in the camp.

I, THE UNDERSIGNED, HAVE CAREFULLY READ AND UNDERSTOOD THIS AGREEMENT AND ALL OF IT'S TERMS. I UNDERSTAND THAT THIS IS A RELEASE AND INDEMNITY AGREEMENT WHICH MAY PREVENT ME OR ANY OTHER PERSON FROM RECOVERING ANY DAMAGES IN THE EVENT OF DEATH OR ANY INJURY TO THE PARTICIPANT. I, NEVER THE LESS, ENTER INTO THIS AGREEMENT FREELY AND VOLUNTARILY AND AGREE THAT IT IS BINDING UPON ME, MY HEIRS, ASSIGNS AND LEGAL REPRESENTATIVES.

This is a liability release. Please read carefully before signing:

Date__________________

Parent/Guardian Signature__________________________________________________________