Heal the Hood Foundation of Memphis Live the Dream Basketball Camp

Heal the Hood Foundation of Memphis
Live the Dream Basketball Camp
REGISTRATION FORM
$5.00 Fee
Friday, June 20, 2014
Time: 9:00am – 2:00pm
Ridgeway High School
2009 Ridgeway Memphis, TN 38119
Heal the Hood Foundation of Memphis have launched events and programs that will aid in
increasing the peace and overall health in our communities that brings together families
throughout the city of Memphis in a fun-filled event with prizes, music and celebrities that
care about the social and emotional health of their fans. This year summer event will launch
with the Living the Dream Basketball Camp for children ages 8 – 16.
Camper Information
Name: _______________________________________________ Age: ______________
Gender: ____M ____F Date of Birth: ________________________________________
Address: ________________________________________________________________
City: _______________ State: ___________________ Zip: ______________________
Phone with area code: _____________________________________________________
Email: __________________________________________________________________
How did you find out about this camp? ________________________________________
Parent/Guardian Information
Parent/Guardian’s Name: ___________________________________________________
Relationship to Child: _____________________________________________________
Home Phone: _______________________ Cell Phone: ___________________________
Address: ________________________________________________________________
Email: __________________________________________________________________
Employer Name: _______________________ Work Phone: _______________________
Please list any special medical conditions, medications, or other relevant info about the
camper. _________________________________________________________________
________________________________________________________________________
Family Physician (Name, address & phone): ___________________________________
________________________________________________________________________
Emergency Contact # 1: ____________________________________________________
Relationship to Child: __________________ Phone: ( ) ________________________
Emergency Contact #2: ____________________________________________________
Relationship to Child: __________________ Phone: ( ) ________________________
Heal the Hood Foundation of Memphis
Live the Dream Basketball Camp
Registration Agreement
I understand that there is a $5.00 fee and is for children between the ages of 8– 16. The camp is
Friday, June 20th from 9:00am - 2:00pm and is limited to a maximum of 400 kids (therefore,
selected campers will be granted on a first come first served basis). I agree to pick my child (ren)
up by 2:00pm on Friday or have authorized persons to pick him/her up by that time. I understand
that if I or the authorized person (s) does not provide adequate transportation to and from the site
that it is not the responsibility of the HTH CEO, staff, participants or the camp hosts to provide
transportation or monies for transportation. I understand that my child must arrive promptly at
Ridgeway High School gymnasium located at 2009 Ridgeway, Memphis, TN 38119.
I agree that my child (ren) will be under the rules of the Ridgeway coach and/or principal, the
HTH staff, participants and/or camp directors reserve the right to disqualify the participation of
my child (ren) for any violation of expectations and rules of the camp. I understand that I will be
expected to remove my child (ren) from the premises safely and expeditiously if such an incident
occurs. I authorize the camp directors/hosts or HTH participants/staff to arrange medical care for
the above named camper. I understand that HTH will not be held liable for any stolen property,
accidents, or providing any form of medical treatment or procedures during or after the summer
basketball camp. Please make sure that your child (ren) has appropriate medical coverage. HTH
will not be responsible for any medical expenses that may occur during your child (ren)’s stay.
By signing this agreement you confirm and acknowledge your (parent/guardian) responsibility
and obligation for any and all property damages. By enrolling in camp, the parent(s) certifies that
the child is amenable to discipline and is free from habits that would make him/her an undesirable
camper, and you release the Heal The Hood Foundation of Memphis (HTH), Shelby County
Schools, its agents, participants, and volunteers from any claims for accident, injury or loss of
valuables that may occur during the camper's stay at Ridgeway High School. You acknowledge
release and waiver of any claim for damages from any such accident, injury or loss.
Child’s Name (Please Print)
______________________________________________________________________________
Parent Signature (s)
Date
______________________________________________________________________________________
Parent Name (s) (Please Print)
Contact Phone # 1
Contact Phone #2
PLEASE RETURN PAGE TO A HTH REPRESENTATIVE
Natasha Hill
[email protected]
Heal the Hood Foundation of Memphis
Live the Dream Basketball Camp
All-Star Celebrity Basketball Game
Saturday, June 21, 2014
3:00pm
Registration Agreement
Camper’s Copy
Heal the Hood Foundation of Memphis have launched events and programs that will aid in
increasing the peace and overall health in our communities that brings together families
throughout the city of Memphis in a fun-filled event with prizes, music and celebrities that
care about the social and emotional health of their fans. This year summer event will launch
with the Living the Dream Basketball Camp for children ages 8 – 16.
I understand that there is a $5.00 fee and is for children between the ages of 8– 16. The camp is
Friday, June 20th from 9:00am - 2:00pm and is limited to a maximum of 400 kids (therefore,
selected campers will be granted on a first come first served basis). I agree to pick my child (ren)
up by 2:00pm on Friday or have authorized persons to pick him/her up by that time. I understand
that if I or the authorized person (s) does not provide adequate transportation to and from the site
that it is not the responsibility of the HTH CEO, staff, participants or the camp hosts to provide
transportation or monies for transportation. I understand that my child must arrive promptly at
Ridgeway High School gymnasium located at 2009 Ridgeway, Memphis, TN 38119.
I agree that my child (ren) will be under the rules of the Ridgeway coach and/or principal, the
HTH staff, participants and/or camp directors reserve the right to disqualify the participation of
my child (ren) for any violation of expectations and rules of the camp. I understand that I will be
expected to remove my child (ren) from the premises safely and expeditiously if such an incident
occurs. I authorize the camp directors/hosts or HTH participants/staff to arrange medical care for
the above named camper. I understand that HTH will not be held liable for any stolen property,
accidents, or providing any form of medical treatment or procedures during or after the summer
basketball camp. Please make sure that your child (ren) has appropriate medical coverage. HTH
will not be responsible for any medical expenses that may occur during your child (ren)’s stay.
By signing this agreement you confirm and acknowledge your (parent/guardian) responsibility
and obligation for any and all property damages. By enrolling in camp, the parent(s) certifies that
the child is amenable to discipline and is free from habits that would make him/her an undesirable
camper, and you release the Heal The Hood Foundation of Memphis (HTH), Shelby County
Schools, its agents, participants, and volunteers from any claims for accident, injury or loss of
valuables that may occur during the camper's stay at Ridgeway High School. You acknowledge
release and waiver of any claim for damages from any such accident, injury or loss.
(PLEASE KEEP THIS PAGE FOR YOUR RECORDS)