Holiday Break Boys Basketball Camp

Holiday Break Basketball Camp Lee’s Summit North High School  Boys and Girls in Grades 1, 2, 3, 4, 5, and 6.  Saturday, December 27, 2014.  @ Lee’s Summit North High School.  From 1:00 p.m. to 4:00 p.m.  Camp Fee: $30.00.  Campers will receive a camp T-shirt and prizes will be awarded for camp contest winners. Campers will also be invited free of charge to a LSN Broncos Varsity Basketball Game and receive autographs after the game. ------Lee’s Summit North Basketball Holiday Camp Registration Name Grade Address Home phone City Zip Birth Date Email Address ______Emergency Contact: T-shirt size: Adult S M L XL Youth S M L Name Contact Phone *LSJBA Player ______If 100 LSJBA players are pre-registered by December 15th , a $500 donation will be made to LSJBA.

I have no knowledge of any physical impairment that would be affected by the camper’s participation in the camp program. I hereby authorize the coaches to act for me according to their best judgement in any emergency requiring medical attention. I further agree to waive all liability of the camp coaches for any accident, illness or other mishap which might befall the camper named on this application while traveling to or from or during attendance at camp. I understand that neither the coaches nor the Lee’s Summit School District provides insurance for injuries incurred during a camp/clinic.

Parent or Guardian Signature______Date______Name of Health Insurance Company ______Policy # ______

Please complete this form and mail it with a $30 check (payable to Lee’s Summit North High School) Send to: Mike Hilbert, Lee’s Summit North High School, 901 NE Douglas St., Lee’s Summit MO 64086, Questions please call 986-3046. WALK UP REGISTRATION WELCOME ON THE 27TH !