NEW LONDON BULLDOGS BOYS SUMMER BASKETBALL CAMP REGISTRATION FORM JULY 22

NEW LONDON BULLDOGS BOYS SUMMER BASKETBALL CAMP
JULY 22nd, 23rd & 24th, 2014
12 – 3 PM
REGISTRATION FORM
PARTICIPANT INFORMATION
Please type or print legibly.
Last Name:
Age: ________
First Name:
T-Shirt Size
Adult: SM
School:
_
MED
LG
XL
__________
Youth: SM
MED
LG
Grade 2014-15: _____________________
Home address:
City:
__
State:
Home Telephone:
Zip Code:
Cell:
_______
(Include area code with telephone numbers)
Parent email:
Emergency contact*:
___________
___ Relationship:
Phone:
Specify any of your child’s health problems:
Is your child on any medication? NO YES
Camp Fees: $40 per Child, $60 max. per Family
If so, please specify:
_____
(includes Camp T-Shirt)
Payments: May be paid by cash or by check. Check payable to: NEW LONDON FAST BREAK CLUB
To be paid on the first day of camp or mail to: New London Fast Break Club, Inc.
P.O. Box 412
New London, WI 54961
Contact Information:
Jason Parker, President NLFBC, High School Boys JV Coach
920-716-1087 call or text
SIGNATURE OF PARENT OR GUARDIAN
DATE
DROP OFF AND PICK UP TIMES
Drop-off time:

11:45 AM
Pick-up time:

3:05 PM (please be considerate of volunteers providing camp)
REQUIRES PARENT’S SIGNATURE:
You have our permission, in the event of an emergency and in case we are unavailable, to authorize any
physician, nurse practitioner or medical personnel to examine, interview, test and if necessary, treat my
child _______________________________________________ as they may deem advisable.
Parent/Legal guardian name _______________________________________________ Date ______________
Parent/Legal guardian Signature ____________________________________________ Date ______________
Participant Allergies ______________________________________________________________________
Participant Medical Problems _______________________________________________________________
I hereby give permission to NEW LONDON FAST BREAK CLUB to photograph and/or videotape the
participant for educational or promotional purposes. ________ (Initial)
PARENT STATEMENT
I hereby state that (camper’s name) ___________________________________________ is in good mental
and physical health condition to participate in the activities provided by NLFBC, including but not limited to all
aspects of basketball related competition. I am fully aware that any activity involving motion or athletic activity
creates the possibility of serious injury. I hereby release NLFBC and its volunteer staff from liability to the
above named athlete, of the person claiming through him/her, arising from injury to the person or property of
the above named athlete occurring in the premises of NLFBC, and New London School District, including
any event performed by NLFBC and or travel to and from such activities.
I understand that NLFBC, has the right to deny admittance to any student not meeting the standards of the
program as it sees fit. I also agree not to hold these parties responsible in the event that my son/child
engages in inappropriate conduct (including, but not limited to disruptive or volatile behavior in or out of
camp, etc.) or becomes involved in any activity or with any persons not associated with NLFBC, or its
scheduled program and that NLFBC, has the right to send him/her home for inappropriate conduct. I further
attest that the information contained in this application is correct to the best of my knowledge. In addition, I
have agreed to the policy and fee statement and agree to comply.
Parent/Legal guardian Signature ____________________________________________ Date ______________