LaunchTrack

First name:

Last name:

Address:

Address2:

City:

Province / State:

Postal / Zip Code:

Parent or Guardian Name:

Parent or Guardian Home Phone Number:

Parent or Guardian Cell Phone Number:

Parent or Guardian Work Phone Number:

Email:

Camper Twitter Handle:

Grade Entering in Fall:

Adult T-Shirt Size:

If you were referred by a coach, please list name:

List high school or youth team (full name). If not on a team, list school:

Position:

Camper Date of Birth:

Camper Height:

Camper Weight:

Primary Guardian:

Parent information if not provided above (Name, Address, Phone Numbers):

Emergency Notification: You must specify a person to be notified if the above parents are unavailable (include phone number and relationship). We will attempt to contact parents first. This must be a person not listed above or residing at the same residence:

Health Care Provider Information (Name/ Phone Number/ Address):

Personal History:

If you checked off any of the personal history boxes please provide details:

Health Insurance Company Name:

Health Insurance Company ID Number:

Health Insurance Company Address:

Health Insurance Subscriber's Name:

Health Insurance Group Number:

Campers Relationship to Health Insurance Subscriber:

Please list prescription and/ or non-prescription medications the camper takes at home (Diagnosis, Name of Medication, Route, Dosage, Frequency).:

Please list medication taken during camp hours including Rescue Inhaler and EPI PEN. This will require health care provider authorization.:

This health history is correct to the best of my knowledge, and the person herein described has permission to engage in all prescribed program activities, except as noted by me. We do herby waive, release, and forever discharge said organization, its staff, officers, agents, representatives, employees, and their successors and assign from any and all claims for damages occurring during the participant’s stay at camp, her participation in activities arising from traveling to or from camp, whether said accident, injury, or loss is due to negligence or not. I hereby give my permission for treatment of illness and injury at the Michelle Campbell Basketball Camp and for emergency medical treatment at the Hospital.:

Accept

HIPAA – Authorization to Disclose Information: I, the parent or guardian of the camper attending the Michelle Campbell Basketball Camp, authorize the use/disclosure of the camper’s individual health information to the Hospital and any other facility which is needed in the event that the camper is hospitalized. I understand that authorizing the disclosure of this health information is voluntary. I can refuse this authorization. I need not accept this section in order to receive treatment. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this information, I must do so in writing and present my written revocation to the Michelle Campbell Basketball Camp Athletic Trainer.::

Accept

Decline

There will be no refunds for any reason. If camp is cancelled for any reason including but not exclusive to inclement weather or act of god there will be no refund. College Coaches, High School Coaches, and Special Guests are subject to change at any time.:

Accept

Registration & guardian