Child Information
Child’s Last Name

First Name MI

Address

City State Zip

Phone (incl. area code) Birth date: (mm/dd/yyyy)

Gender Age Grade Child is Entering

What Camp(s) will you be attending: Basketball Floor Hockey Flag Football

Years of sports experience in - Basketball Floor Hockey Flag Football

Family Information
Father Best number to be contacted

Mother Best number to be contacted

Medical Release Information
As the parent or legal guardian of the above mentioned player, I hereby give my consent for emergency medical treatment/care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions may be necessary to preserve life, limb, or well-being of my dependent.

Parent/Guardian Printed Name

Parent/Guardian Signature (to be signed upon arrival)

Insurance Company

ID# Group#

Child’s Doctor Doctor Phone

Person to notify in case of emergency and phone

List any and all health problems, limitations and allergies: