application form

WARHAWK
BASKETBALL
2016 Warhawk Men’s Basketball Camp
PARENTAL CONSENT FORM
I
hereby authorize the staff of the University of
Louisiana at Monroe/Warhawk Men’s Basketball
Camps to act for me according to their best
judgment 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 camp. I have no knowledge of any
physical impairment that would be affected by
_________________________________________
(Camper Name)
I hereby give the University of Louisiana at Monroe/
Warhawk Men’s Basketball Camps permission to
publish and release information about the above
named minor student, including his/her photograph,
to the news media. In addition, I give the University
of Louisiana at Monroe/Warhawk Men’s Basketball
Camps permission to publish and copyright
photographs and/or video footage of him/her and
other information about him/her for any advertising
and/or promotion done in any printed or electronic
form.
I also certify that I am the legal parent or guardian
of the above named student and have full right to
provide this release.
_________________________________________
Parent/Legal Guardian’s Printed Name Date
_________________________________________
Parent/Legal Guardian’s Signature
Date
University of Louisiana at Monroe
Men’s Basketball Camp
308 Warhawk Way • Monroe, LA 71209
participation in the camp program, as outlined
above.
MEN’S
BASKETBALL
CAMPS
June 27-30, 2016
August 1-4, 2016
CAMP INFO
2016 Warhawk Men’s Basketball Camps
offer two individual camps this summer. Each
camp includes snacks, bottled water, a t-shirt
and prizes.
June 27-30, 2016
Ages:6-17
Check-in: 7:30 a.m.-8:20 a.m.
Fant-Ewing Coliseum
Camp Time: 8:30 a.m.-12 p.m.
Cost:$100
August 1-4, 2016
Ages:6-17
Check-in: 7:30 a.m.-8:20 a.m.
Fant-Ewing Coliseum
Camp Time: 8:30 a.m.-12 p.m.
Cost:$100
Deposit:
Checks payable to:
$50 (non-refundable)
Warhawk Men’s
Basketball Camp
Warhawk Men’s Basketball Camps are
run by ULM Head Basketball Coach
Keith Richard and his staff.
Please fill out the information below and sign
the parental consent form on the back. Return
this form with the $50 deposit to:
Keith Richard is in his
sixth season as the
head men’s basketball
coach for the ULM
Warhawks. He is the
second ULM head
coach – joining Mike
Vining – to have been
a student-athlete and a
coach for the program.
Warhawk Men’s Basketball Camp
308 Warhawk Way • Monroe, LA 71209
Name:________________________________
Camp selection: (circle one)
June 27-30
August 1-4, 2016
T-shirt size: (circle one)
Richard’s background is highlighted by 31
years of Division I coaching experience,
including 28 in the state of Louisiana.
Youth:
Adult:
S
S
M
M
L
L
XL
XL
School:_______________________________
For more information, please contact:
Camp Director, Luke Richard
(318) 237-2575 • [email protected]
_____________________________________
Age:_________Grade as of June 1:_________
MAIL APPLICATION FORM TO:
Street Address:_________________________
Warhawk Men’s Basketball Camps
Attn: Luke Richard
Fant-Ewing Coliseum
308 Warhawk Way • Monroe, LA 71209
PLAY
HARD
2016 Warhawk Men’s Basketball Camp
CAMPER INFORMATION
_____________________________________
City, State, Zip Code:_____________________
!
_____________________________________
Home/Cell Phone:_______________________
_____________________________________
Emergency Phone:______________________
Name of Parent or Guardian:______________
_____________________________________