CAMPER S NAME: _____________________________________________ STREET ADDRESS: ___________________________________________

1. CAMPER�S NAME: _____________________________________________STREET ADDRESS: ______________________________________________________________CITY/STATE/ZIP:_______________________________________________EMAIL ADDRESS:______________________________________________POSITIONS YOU PLAY:_________________________________________GRADE: _____ AGE: ____ SCHOOL:______________________________CAMP SHIRT (circle one) Youth L, Adult S, Adult M, Adult L, Adult XLPARENT�S NAME(S):___________________________________________CONTACT PHONE NUMBERS:___________________________________EMERGENCY CONTACT NAME & PHONE NUMBER:I hereby authorize the staff at the South County STALLIONS Winter Training Clinic to act for me according to their best judgment in the event of an emergency requiring medical attention and I hereby waive and release the clinic from any liability for anyinjuries and illness incurred while at the clinic. I have no knowledge of anyphysical impairment that would affect the participation of my child in the clinicprogram as outlined in this brochure.Parent Signature: ________________________ Date:________________Make checks payable to: SCABC - BaseballMail Registration & Check to: South County Secondary School, 8501 Silverbrook Road; Lorton, Virginia 22079Attn: Mark Luther � Winter Training Clinic - Baseball Winter Training Clinic Sunday, Jan 29th, Feb 5th , Feb 12th (Ages 8-14 / Grades 4-8) Location: South County SS Gym Time: 12:00 � 2:30pm Fee: $85 (includes camp shirt) $75 additional family members. What to Bring: Wear tennis shoes (no cleats) & Sweatpants or Baseball Pants, Glove, Bat, & Helmet. Bring water bottle. Deadline: Register by January 25, 2012 Space is Limited! Register Early!! Questions: Coach Mark Luther 703-446-1680, Mark.Luther@fcps.edu or Robbie Smith � 703-446-1578, Robbie.Smith1@fcps.edu. Additional registration forms can be found at http://www.stallionsports.org/