Basketball Clinic June 3-7th, 2024 Register Below First Name *Last Name *Gender *MaleFemaleDate of BirthGrade Select *Grade Entering in Fall of 20241st2nd3rd4th5th6thCONTACTStreet Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Family Phone *Family Email Address *Father's/Guardian #1's Name *Emergency Phone *Mother's/Guardian #2's Name *Emergency Phone *Camper lives with (if different than address listed above)Relationship To The CamperCamper's Home ChurchCity Church is located in *State Church is located in *ALL CAMPERS SHOULD BE AWARE AND AGREE:Rules: 1) I will at-all-times listen to and respect all authority figures of the New Life Baptist Church basketball skills staff. 2) I understand that if I cause a disruption and am asked to leave, that I forfeit any awards. 3) New Life Baptist Church will not transport any campers home during the camp time. If I am asked to leave, my parent or guardian will be responsible to pick me up immediately. 4) This is a skills camp, not a team tournament. There will not be team competitions or games played. All instruction is one-on-one to make each camper a better athlete. 5) There will be services of Bible teaching as well as basketball skills. All campers will be expected to participate respectfully.Camper's Signature *Start signing your signature hereYour browser does not support e-Signature field.“I, the camper, understand that the main purpose of this camp is to help me: 1) learn basketball skills, and 2) grow spiritually. The rules of the camp are based on the Christian value system. I, the camper, have read the rules above and agree to cooperate fully.”Select T-Shirt SizeIndicate Shirt size of CamperYouth S (6/8)Youth M (10/12)Youth L (14/16)Adult SAdult MAdult L (+$2)Adult XL (+$2)Adult XXL (+$2)Adult XXXL (+$2)HEALTHCamper's Legal First Name *Camper's Legal Middle NameCamper's Legal Last Name *Date of BirthRequired - Year of Last Tetanus Booster(Sometimes referred to as DTP or Td or Tdap on health forms.)Check boxes for up to date Vaccinations as required for school entryDiptheria - Tetanus - Pertussis Series (DTP)Hepatitis B SeriesPolio SeriesVaricella (or had “chicken pox”)Measles - Mumps - Rubella (MMR)PLEASE NOTE if camper has any of the followingConvulsive DisordersChronic/Recurring IllnessFrequent Ear InfectionsContagious Disease(s)Recent Illness or InjuryADD/ADHDSpecial Conditions to be watched forOverall Good Health to participate in camp activitiesRecent conditions that may restrict this camper from certain camp activities(Optional) Any recent life changes (death in the family, divorce, etc.)Recent Illness or Injury *Contagious Disease(s) *Special Conditions to be watched for *Overall Good Health to participate in camp activitiesRecent conditions that may restrict this camper from certain camp activities *Optional: Any recent life changes (death in the family, divorce, etc.)Does the Camper have any allergies we need to be aware of? *YesNoList Allergies, reactions and managementPlease list any food, medication, insect, etc. allergies & describe reaction & management of reactionDoes your camper take any medications (Prescription/Over-the-counter/Herbs)? *YesNoAll medications must be in original container & turned in upon arrival.Name of Medication *This must be in original container & turned in upon arrival.Dosage *Reason for taking *More medicationI have more medication to declareName of Medication *This must be in original container & turned in upon arrival.Dosage *Reason for taking *More medicationI have more medication to declareName of Medication *This must be in original container & turned in upon arrival.Dosage *Reason for taking *More medicationI have more medication to declarePlease list any additional medications your camper will need to take *Be sure to include the name of the medication, the dosage and the reason for taking“My child may be given over-the counter medication as deemed necessary by the camp staff, according to protocol, for comfort measures.”Please sign or initial to give consent to the above statement.Your browser does not support e-Signature field.(Aspirin will NOT be given) ExceptionsWeight of camper (for dosage)Camper’s PhysicianPhysician PhoneHealth Insurance InformationInsurance CompanyPolicy/Group #Insured’s Name (not camper)Insured’s Date of Birth (not camper)Emergency Phone NumbersParent/Guardian NamePhone #’s w/ area codesIf Parent/Guardian is not available, please contactNamePhoneRelationship to camperIn the event of emergency, I give NLBC permission to care for and transport my child for any needed medical assistance. I hold N.L.B.C. harmless for any potential injuries that may occur.SignaturePlease sign or initial to give consent to the above statement.Your browser does not support e-Signature field.NameRelationshipSubmit