COACH RUDD'S BASKETBALL CAMP REGISTRATION FORM 2023
Complete a form for each child, if more than one.
Camper Name: ___________________________________________				Camp Weeks:
Age: _______	Grade: _______	(as of September)	Shirt size: _____	(Circle your week of choice)
				Week 1: June 26-29
Parent Name: ____________________________________________				Week 2: July 10-13 Week 3: July 17-20 Week 4: July 24-27
Ad dress: ________________________________________________
City: _______________________		State: _______ Zip: ___________		Cost: $150/week, per camper
Phone Number: __________________________________________
Email Address: ___________________________________________				Camp Time: 9:00am - 3:00pm
MEDICAL CONSENT/WAIVER OF LIABILITY
*ALL CAMPERS MUST HAVE PRIMARY ACCIDENT INSURANCE*
Insurance Company Name: ____________________________________________
Health History (Check all that apply)
c	Allergies	c	Diabetes	c	Penicillin
c	Asthma	c	Hay Fever	c	Seizures
c	Other: _______________________________________________________________
Medications: _________________________________________________________________________
Emergency Contact: ___________________________________________________________________
Phone: _________________________________			Relationship to Camper: ____________________
CAMP RELEASE:
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.
Parent Signature: __________________________________________________ Date: _____________