VIKING ALL-STAR BASKETBALL CAMP APPLICATION
(Print out application and mail to address shown below)
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Name:________________________________
Address:______________________________
Home Phone:__________________________
Cell Phone:____________________________
Email Address:_________________________
School:________________________________
Age:_______
T-Shirt Size:______ (S, M, L, XL, XXL)
(Adult Sizes)
| Please Check:
_____ Week 1 July 11th - July 15th 2011 $175.00
_____ Week 2 July 25th - July 29th 2011 $175.00
_____ Both Weeks ($25.00 off total) $325.00
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Health and Medical Record
Camper Name:
_______________________
Emergency Contact Person:
________________________
Emergency Contact Number:
_________________________
| Health History
___ Asthma ___ Diabetes ___ Convulsions
___ Fainting Spells ___ Heart Condiotions
___ Alergy or Reaction to Medication
___ Other____________________
___ Any restrictions of activity for medical reason?
If yes please explain:_________________________
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Medical Release Form:
I hereby authorized the staff of the Viking's All-Star Basketball Camp to act for me in accordance with their best judgement in any emergency requiring medical attention and I hereby waive and release the camp from any and all liability for any injuries or illness incurred while at the camp. Other than the above medical history, I have no knowledge of any physical impairment that would affect the above named camper's participation in the camp program.
____________________________ _________
Parent/Guardian Signature Date
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Make checks payable to:
Joe Murphy Basketball Camps
P.O. Box 2171
Cinnaminson, NJ 08077
Balance Due on or Before July 1, 2011
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