Name

Age (at time of camp)

Grade (next fall)

School

Birthday

Address

City, ST  Zip

Parent/Guardian

Home Phone

Emergency Phone

□  July 14-18 (Boys) - $210
□  July 21-25 (Boys) - $210
□  July 28-August 1 (Girls) - $210

Shirt size

Family Medical Insurance Company

Policy Number

Parent or Guardian must sign the following:

The applicant is in good health and able to participate in the physical activity of a vigorous program. The camp has my permission to provide emergency medical care in the event my child is injured or ill. I also release the Camp Directors and Staff from any liability. Medical documentation citing any limitations must accompany this application.
 

Signature

Date

Enclosed is the deposit of $50.
Balance due by the first day of camp.

Enclosed is the total payment ($210).

Make checks payable to South Shore Basketball Academy.