South Shore Basketball Academy

Register ONLINE (Complete form)
	First Name
	Last Name
	Birthday	ex. mm/dd/yy
	Address
	City
	State
	Zip Code
	Age (at time of camp)
	Grade (next fall)
	School
	Parent/Guardian
	Home Phone	ex. (###) ###-####
	Emergency Phone	ex. (###) ###-####
	Email Address
	Camp Week
	Shirt Size
	Family Medical Insurance Company
	Policy Number	(Insurance information is required before child can attend camp.)
	Referral Source
	Referral's Name (if Friend)
		Please check box in lieu of signature that you agree 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.