COACH RUDD'S BASKETBALL CAMP REGISTRATION FORM 2023 |
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Complete a form for each child, if
more than one. |
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Camper Name: ___________________________________________ |
Camp
Weeks: |
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Age: _______ |
Grade: _______ |
(as of September) |
Shirt size: _____ |
(Circle
your week of choice) |
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Week
1: June 26-29 |
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Parent Name: ____________________________________________ |
Week
2: July 10-13 Week 3: July 17-20 Week 4: July
24-27 |
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Ad dress: ________________________________________________ |
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City: _______________________ |
State: _______ Zip:
___________ |
Cost: $150/week, per camper |
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Phone Number: __________________________________________ |
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Email Address: ___________________________________________ |
Camp
Time: 9:00am - 3:00pm |
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MEDICAL CONSENT/WAIVER OF LIABILITY |
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*ALL
CAMPERS MUST HAVE PRIMARY ACCIDENT INSURANCE* |
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Insurance Company Name:
____________________________________________ |
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Health History (Check
all that apply) |
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c |
Allergies |
c |
Diabetes |
c |
Penicillin |
|
c |
Asthma |
c |
Hay
Fever |
c |
Seizures |
|
c |
Other:
_______________________________________________________________ |
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Medications: _________________________________________________________________________ |
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Emergency Contact: ___________________________________________________________________ |
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Phone: _________________________________ |
Relationship to Camper:
____________________ |
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CAMP RELEASE: |
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c In
consideration of making facilities and/or services available, I do hereby for
and on behalf of myself and my heirs, and legal representatives, release and
forever discharge all Glen Burnie High School and/or any of its staff from
any and all claims and demands of every kind, nature and character which I,
or my child, may have or hereafter acquire for any and all damages or losses
which may be suffered or sustained by me, or my child, in connection with our
activity and all such claims are hereby waived and released. |
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Parent Signature:
__________________________________________________ Date: _____________ |