Registration Form for:

TAMAQUA LADY RAIDERS BASKETBALL CAMP

GIRLS ENTERING GRADES 3rd-8th

Tuesday July 22nd, Wednesday July 23rd, Thursday July 24th

5:00-8:00 PM

Full Name of Camper: ______

DOB: ______AGE: ______ENTERING GRADE: ______

HEIGHT: ______POSITION: ______YEARS PLAYED: ______

Shirt Size Preference, please circle one:

Youth— SM MD LG

Adult— SM MD LG XL

HOME ADDRESS: ______

______

______

E-MAIL ADDRESS: ______

PHONE NUMBER: ______

If not available, list an emergency contact name & number:

PRE-EXISTING CONDITIONS:

Does your child have any injuries or conditions that presently exist that would limit her from camp activities?

Yes No If yes, please describe: ______

______

______

Does your child use an inhaler for asthma?

Yes No

Mail completed form, parent/guardian signature, and camp fee to:

Erika Davis

275 Mush Dahl Rd.

New Ringgold, PA 17960

Checks can be made out to: Erika Davis

Please read below and sign/date:

I acknowledge that participation in basketball camp has an inherent risk. The child named on this form has my permission to participate in the designated Tamaqua Lady Raiders Basketball summer athletic camp. I understand that camp participation will involve significant physical activity, which could result in injury. I certify that my child is in good physical condition and is fully able to participate. I assume all risk incident to my child’s participation and release Tamaqua Lady Raiders Basketball Camp Staff and Tamaqua Area School District employees, agents, offices, and volunteers from all liability claim, expenses, and actions, which may arise from injury or harm to the child as a result of camp participation. In the event of a medical emergency, I authorize the Tamaqua Staff to designate a hospital, physician, or emergency personnel to provide care (including hospitalization, if necessary) to the child and release Tamaqua Staff and School District from any liability for injury or harm to the child that may result from this medical care. I understand and certify that responsibility certify that my child is covered by adequate medical insurance. Please understand that the Tamaqua Lady Raiders Basketball Camp is not responsible for and does not carry insurance. Parents and/or guardians must provide insurance for their child.

Parent/Guardian Signature______

Parent/Guardian Name Printed ______

DATE: ______

Registration deadline: Sunday July 13th – any registration forms will be accepted after this date, however, a t-shirt will not be guaranteed!