Basketball Clinic

First Name *

Last Name *

Gender *MaleFemale

Date of Birth

Grade Select *

CONTACT

Street Address *

Apartment, suite, etc

City *

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 Camper

Camper's Home Church

City 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 *

“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.”

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HEALTH

Camper's Legal First Name *

Camper's Legal Middle Name

Camper's Legal Last Name *

Date of Birth

Required - Year of Last Tetanus Booster(Sometimes referred to as DTP or Td or Tdap on health forms.)

Recent Illness or Injury *

Contagious Disease(s) *

Special Conditions to be watched for *

Overall Good Health to participate in camp activities

Recent 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? *

YesNo

List Allergies, reactions and managementPlease list any food, medication, insect, etc. allergies & describe reaction & management of reaction

Does 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 medication

I have more medication to declare

Name of Medication *This must be in original container & turned in upon arrival.

Dosage *

Reason for taking *

More medication

I have more medication to declare

Name of Medication *This must be in original container & turned in upon arrival.

Dosage *

Reason for taking *

More medication

I have more medication to declare

Please 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.

(Aspirin will NOT be given) Exceptions

Weight of camper (for dosage)

Camper’s Physician

Physician Phone

Health Insurance Information

Insurance Company

Policy/Group #

Insured’s Name (not camper)

Insured’s Date of Birth (not camper)

Emergency Phone Numbers

Parent/Guardian Name

Phone #’s w/ area codes

If Parent/Guardian is not available, please contact

Name

Phone

Relationship to camper

In 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.

Signature

Name

Relationship

Register Below

CONTACT

ALL CAMPERS SHOULD BE AWARE AND AGREE: