Peyton Summer Basketball Camp

Camp Director: Jedd Sims Email: Cell Phone: (845)-337-9077

When: Monday, June 20th– Friday, June 24th Where: Peyton High School Gym

Time: 8:30-12:00 Who: Entering Grades 3-9 Cost: $55.00

Camp Registration Form

Camper Information:

Camper Name:______

Grade Entering (fall 2016):______Date of Birth:______

Allergies/Medical Conditions:______

Plan of Action:______

Shirt Size (Please Circle One)YS YM YL YXL AS AM AL

Parent/Legal Guardian Information:

Mother’s Name:______

Cell Phone:______

Father’s Name:______

Cell Phone:______

Home Address:______

City/State/Zip Code:______

Email Address:______

Emergency Contact Information:

Emergency Contact Name:______

Cell Phone: ______May we release to this contact: Y/N

Relationship to Camper:______

Hospital Preferred:______

Medical Release

As a parent or legal guardian of the registering player, I hereby give consent for emergency medical care as prescribed by a duly licensed doctor of medicine or doctor of dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent.

Warning Statement

Although participation in supervised athletics may be one of the least hazardous in which any youth will engage, by its nature, participation includes a risk of injury which may range in severity from minor to long term catastrophic. Although serious injuries are not common in supervised athletic programs, it is impossible to eliminate this risk. Participants have the responsibility to help reduce the risk of injury. Players must obey safety rules, report all physical problems to the youth camp director, follow a proper conditioning program, and inspect their equipment daily.

Parental Waiver

As a parent or legal guardian for the child that I am registering, I hereby understand and agree to the following:

• My child may participate in all practices, games and meeting and any activities associated with this camp

• My child is physically fit to participate in this camp

• By its nature, competitive athletics may put participants in situations in which serious, catastrophic and perhaps fatal accidents may occur.

• I assume all risks and hazards incidental to such participation, including transportation to and from these activities.

• Peyton School District 23JT and any camp coach affiliated with Boys Basketball team is not responsible to provide accidental insurance for the players, and any such coverage I deem necessary is my responsibility.

• I hereby waive, release, resolve indemnify and hold harmless the Peyton School District 23JT and any other league with which we affiliate, sponsors, officers, supervisors, coaches, umpires, and any parties, against any claim arising from an injury, whether the result of negligence or any other cause.

Parental Signature Required

By registering, you acknowledge that you have read and understand this warning. Parents/Legal Guardians are responsible for any and all fees resulting from a medical emergency.

• Signature of parent or legal guardian—by signing below you are assuming all responsibility and acknowledge that you have read and understand the warning statement above.

Parental Signature:______Date___/___/____