Memphis Kings Basketball Camp

Memphis Kings Basketball Camp Hosted by: Saint John’s Episcopal Church 3245 Central Ave.

June 2-5 Girls & Boys Ages 6-10 Mon-Thurs • 12:00 - 4:00 Your Kids Will Experience Fun Games, Sports Skills, Teamwork Bring Water bottles COST: $85 week , $25 per day  T-shirt  Daily devotional  Snack  Awards, prizes and giveaways

Payment Method Cash or Check to Memphis Kings Email: [email protected] Contact: Sam Davis 901-299-0340

MEMPHIS KINGS BASKETBALL CAMP REGISTRATION FORM MEDICAL HISTORY, AND RELEASE Note: This form and payment is required prior to participation in summer sport camps. PLEASE PRINT USING BLACK INK

CAMP DATES:______

PARTICIPANT INFORMATION

NAME: ______AGE: ______DATE OF BIRTH: ______First, Last

HOME ADDRESS: ______Street Address City State Zip

SCHOOL: ______GRADE FALL 2013: ______SHIRT SIZE

FATHER/GUARDIAN NAME: ______

EMAIL: ______

PHONE: Home (______) ______Work (______) ______Cell (______) ______

MOTHER/GUARDIAN NAME: ______

EMAIL: ______

OTHER/EMERGENCY CONTACT PERSON NAME: ______

ALLERGIES ⇒If yes, please list the allergy and provide additional information if necessary. Insect bites/stings NO YES ______Medications NO YES ______Food NO YES ______Other NO YES ______RELEASE OF LIABILITY: I/we the undersigned, for ourselves, our heirs, executors and administrators, waive, release and forever discharge the Memphis Kings Basketball staff, officers, agents, employees, representatives, successors and assignees of and from all rights and claims for damages, injuries or losses of personal property which may be sustained or occur during participation in camp activities while at camp.

CONSENT FOR TREATMENT: I hereby give my permission to a camp certified athletic trainer to supervise on-site first aid for minor injuries. In the event of injury such as broken limb, sprain, contusion, laceration, concussion, etc., or illness requiring medical diagnosis or treatment, I hereby give my consent for sports camp staff to secure the proper medical care; including transportation and hospitalization, if necessary. Every attempt will be made to contact the parent or guardian to inform you of the need for any medical attention beyond minor first aid, if necessary.

IMPORTANT: MY SIGNATURE BELOW INDICATES THAT I HAVE READ AND UNDERSTAND THESE TERMS

PRINT NAME:______DATE:______SIGNATURE:______RELATIONSHIP TO PARTICIPANT:______