2005 OCC League Champs, 2005 District Champs, 2005 Sweet 16 Div. 1 – Ohio

2006 District Semi-Finalists, 2007 District Semi-Finalists, 2010 District Semi-Finalists, 2013 OCC League Champs

LITTLE DRIBBLERS BASKETBALL CAMP

SUMMER 2013

BASKETS WILL BE SET AT 8 FEET

May 28-May 31st

Who: Any girls going into 1ST OR 2ND Grade (2013-14)

When: May 28-May 31st (Tues. – Fri.) 8:00 am – 9:30 am

Cost: $50 – please pay by May 24th

$55 Late registration will also be available the 1st day of camp @ 7:30 am

Where: WESTERVILLE NORTH HIGH SCHOOL Main Gym & Aux. Gym

Why: To learn the fundamentals of basketball and have fun!

There will also be INDIVIDUAL & TEAM COMPETITIONS

How: Fill out the registration form attached, make the check out to

WNABC (Westerville North Athletic Booster’s Club) & send to:

Coach Jim Kloepfer Drop off the form &

5824 Pinewild Drive or check at the Athletic

Westerville, OH 43082 office at West. North

Questions?

Call or Email Coach Kloepfer

Phone: 797-6220 Email:

PLEASE COMPLETE THE FORM BELOW AND SEND IT ALONG WITH THE CHECK MADE OUT TO WNABC (Please note that the check is for girls basketball) TO COACH KLOEPFER OR DROP IT OFF AT WESTERVILLE NORTH HIGH SCHOOL IN THE ATHLETIC OFFICE

Name: ______grade next school year (2013-14): ____

t-shirt size (circle one) YM YL S M L XL XXL

Injury and Insurance Release Statement: I give my permission for my daughter to participate in the Lady Warrior Basketball Camp. In addition I agree to accept any and all liability in case of accident or injury.

Parent (guardian) signature for insurance release: ______

*YOU MUST ALSO COMPLETE THE EMERGENCY MEDICAL FORM BELOW

Emergency Medical Authorization

Section 3313.312 Ohio Revised Code

______

(athlete’s name) (phone) (parents and/or guardians)

______

(street address) (city) (zip code) (e-mail)

Purpose: To enable parents to authorize emergency treatment for children who become ill or injured while under school authority, when parents cannot be reached.

Part I or Part II must be completed.

Part I – CONSENT – In the event reasonable attempts to contact me (name)______

@ phone # ______or (name) ______@ phone # ______have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by (preferred physician) ______@ phone # ______or (preferred dentist) ______@ phone # ______, or in the event that the preferred practitioner is not available, by any other licensed physician or dentist, and (2) transfer of the child to (preferred hospital) ______or any other hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained before the surgery is performed. Facts concerning the child’s medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted: ______

______

(date) (Signature of parent/guardian)

Part II – REFUSAL TO CONSENT – I do not give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish school authorities to take no action or to: ______

______

(date) (Signature of parent/guardian)