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: _____________