Registration Form

All areas of this form must be completed prior to camper’s participation

Event / Camp Date

Player Information

First Name Last Name Address City State Zip Home Phone Cell Email Rising Grade Age DOB   School Height Weight Gender Male Female T-Shirt Size YS YM AM AL AXL

Parent/Guardian Information

First Name Last Name Employer Work Address Home Phone Cell Phone Work Phone Email Address

Parental Consent/Release

This completed form will enable health facilities and the staff of OverTime to provide good care to your child in case of emergency.

Allergic reactions (drugs, food, etc.)? No Yes     If yes, please describe Currently taking medications? No Yes     If yes, please describe

In Case of Emergency

Contact Name Contact Phone Insurance Provider Policy# Policy Holder         I (Parent / Guardian) hereby acknowledge and agree that there is risk of serious injury and/or loss associated with child’s participation in the OverTime Basketball Camp at Samson’s Health & Fitness Center. As a condition of child’s participation, we assume that risk and forever waive and agree to hold OverTime Basketball Academy and Samson’s Health & Fitness Center harmless from any and all claims, liabilities, and/or damages arising out of child’s participation in the camp. I understand that the child will not be permitted to participate in the program without signing this agreement.