2015 Basketball Camp Registration Form and Information

A community
partner
program by:
2015 MIAMI COUNTY
Community Basketball &
Volleyball Camps
at TigArena
Sponsored by:
GIRLS Combined
Basketball & Volleyball Camp
BOYS Basketball Camp
Monday, June 15 – Friday, June 19
Grades 1-4* 1-2pm
Grades 5-8* 2:30-4pm
*Based on grade entering in the fall
Monday, June 15 – Friday, June 19
Grades 1-4* BB: 9:30-10:45am; VB: 11am-12:15pm
Grades 5-8* VB: 9:30-10:45am; BB: 11am-12:15pm
*Based on grade entering in the fall
Location: Peru High School TigArena
Location: Peru High School TigArena & Tiger Den
Contact: Head Coach Jim Metcalfe
765-475-6834
[email protected]
Basketball: Head Coach David Weeks: 472-4271
[email protected]
Volleyball: Coach Katie Wyant: 244-0538; [email protected]
REGISTRATION FORM
Registration can be completed at any Peru School (Athletic or Admin Office; checks payable to Peru
Basketball) or the Miami County YMCA (checks payable to YMCA).
Fee: $25/participant, includes T-shirt & all activities.
Pre-registration is encouraged to ensure T-shirts are delivered in quantity and on time; walk-in
registrations on the first camp day will also be accepted. Financial assistance is available through the YMCA.
CHECK ONE:
__ Boys Basketball
__ Girls Basketball & Volleyball*
*no additional fee for combined camp
__ Girls Basketball Only
__ Girls Volleyball Only
Name:__________________________
Telephone:_________________
Address:_______________________________
Age:________
T-Shirt size (Circle): Youth: Small
Medium
Gender: M
Large
F
Adult: Small
2015-16 Grade:__________
Medium
Large
XL
Parent/Guardian Names:____________________________________________________
Name(s) of Emergency Contact:______________________________________________
Emergency Phone Number:_____________________ Relationship:_________________
WAIVER OF LIABILITY AND DISCLAIMER
To induce the Miami County YMCA (YMCA) and Peru Community Schools (PCS) to accept registration and permit
participation in the program by the named individual, I hereby agree to release, indemnify, and hold harmless the YMCA
and PCS, its officials, coaches, and representatives from any claim arising out of injury to the named individual. We also
hold harmless the YMCA and PCS, its officials, coaches, and representatives, from any claim arising out of injuries or
conditions caused by or aggravated by our/my refusal to obtain available medical treatment based on religious or
philosophical beliefs.
I hereby certify that the named individual is in normal health and capable of safe participation in this program. I
assume all risks and hazards incidental to the conduct of this program and for the transportation to and from the
program. I hereby authorize the YMCA and PCS to obtain medical treatment for the named individual in the event that
the emergency contact (or parent if applicable) cannot be reached.
Parent or Guardian Signature: ___________________________________
Date: ____________________
SPORTS
STRENGTHEN
CHARACTER
Miami County YMCA
34 E. 6th St.
Peru, IN 46970
Community
Basketball &
Volleyball
Camps For
Grades 1-8
June 15-19
Basketball Camps for Boys entering Grades 1-8
Basketball & Volleyball Camps for Girls entering Grades 1-8
Boys: June 15-19
Girls: June 15-19
Led by Peru HS Varsity coaches at TigArena & Tiger Den
$25/participant
Complete enclosed form and return to the Y or
any Peru School office by June 12.
MIAMI COUNTY YMCA
More info: 765-472-1979
[email protected]