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 ______________