Basketball Summer Camp Registration Form
4-Day Camp for All Rising 9-12thHS Girls
3-Day Camp for All Rising 9-12th HS Boys
Please fill out and return Camp Registration Form with Check Payable to TKA Athletics
Send to TKA Athletic Department by deadline to secure your tee shirt.
Call School Office for Summer Office Hours: (770) 592-5464
Contact HS Girls: Coach Cundiff, - Contact HS Boys: Coach Hereth,
STUDENT INFORMIATION:
Student Name: ______Date of Birth: ______
Age: _____ Grade Entering Fall of 2017: ______Enrolled at The Kings Academy: Yes ____ No ____
Homeschool, Public or Private school currently enrolled in:______
My student played for another Basketball Team: Yes____ No ____ Team Name: ______
CONTACT INFORMATION:
Student Address: ______City______Zip:______
Parents Name: ______
Mother’s Cell: ______Father’s Cell: ______
Parents’Email: ______
REGISTRATION:
My student will be attending the following basketball camps at the Kings Academy Gym:
High School Girls (grades 9-12th): _____High School Boys (grades 9-12): ______
June 12-15 from 6-9 p.m.June 26-28 from 6-9 p.m.
Cost Per Student: $100.00Cost Per Student: $50.00
Deadline for Registration is June 2ndDeadline for Registration is June 16th
Tee Shirt Size: ______Tee Shirt Size: ______
MEDICAL RELEASE
Does your child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness, maintenance medications or other significant medical conditions? ______If yes, please state conditions:
______
May we administer common first aid treatment on site if needed? Yes ____ No ____ This would include Band-Aids, Ace bandages, analgesics (such as Tylenol, Ibuprofen, etc.). Please specify any restrictions:
______
Emergency Authorization:
I the undersigned, parent or legal guardian of the participant, a minor, hereby authorize the supervising adults or volunteer parents acting in the capacity of activity supervisors, as my Agents, to consent to medical, surgical or dental examination and/or treatment. In case of emergency, I hereby authorize treatment, and/or care at any hospital. If there is an emergency and I cannot be reached, please contact the above emergency contact.
Waiver of Liability and Disclaimer:
I, the parent or legal guardian of the above-named individual, acknowledge that participation in athletic events necessarily involve risk of physical injury. I further acknowledge that parents and other adults, who volunteer their time, rather than paid professionals, primarily administer this program. In consideration for accepting the registration of the above-named individual and permitting the voluntary participation of said individuals in this program, I hereby release, discharge, and hold harmless the volunteers and other associated representatives from all claims, demands, liabilities, and causes of action arising out of or relating to any injury that may result to said individual while participating in this program.
Signature of Parent/Guardian: ______Date: ______