Each participant must have a separate registration form. Stan Holt Camp Application Please submit this form to the registration table on the first day of camp. All participants must have this form on file prior to participation. Camper Name______________________________________ Please circle Yes or No for the following: Parent Name:______________________________________ Current Medical Condition: Relationship:_______________________________________ Under Treatment YES NO Pre-Existing Injuries YES NO Address___________________________________________ Fractures or Other Types of Injuries YES NO City/State_________________________ Zip_____________ Allergy YES NO Medical Disorder YES NO Email Address______________________________________ Contact Lenses YES NO Explain “Yes” Answers Below: Phone (H)________________ (W)_____________________ _____________________________________________________ Phone (Mobile)_____________________________________ MEDICAL RELEASE & ACKNOWLEDGMENT FORM Birthdate_______________ Age_______ Ht.____Wt.______ This release is executed and acknowledged on the ____ day of _________, 2016 by the parent and/or Guardian of ___________________, hereinafter Entering Grade in Fall_______________________________ referred to as “Releasor”, for good and valuable consideration does for himself and personal representatives, heirs, assigns and next-of-kin, hereby T-SHIRT SIZE (Circle) — Boys OR Mens release, waive, forever discharge, indemnify and covenant not to sue the Board of Regents of the Oklahoma State, Langston University, its officers, S M L XL XXL members, employees, agents and representatives, hereinafter collectively referred to as “Releasees”,and agrees to hold harmless, defend and indemnify the same, for any and all loss, damages, claim, demand, action or ⧠ Day Camp (Ages 7-14, Boys and Girls)........... August 1-5 right of action of whatsoever kind or nature either in law or in equity, arising Check-in/Register 8:00am Daily Drop Off: 8:30am from or by reason of any personal injury, known or unknown, death and/ or property damage resulting or to result from participation in Stan Holt Camp Hours: 9:00am -12:30pm (Mon-Fri) Basketball Camp, Coach Holt Basketball Camp operated by Stan Holt on the $99.00 Camp Fee — Early Bird Discount Avail. Online Only Langston University Campus. Further, I recognize and acknowledge the TAN OLT potential risks and dangers involved in participation in such a camp and its ⧠ Elite Camp...(Ages 14-18, Boys Camp)...............August 6 S H related activities including travel related to field trips and other camp activities. I acknowledge and hereby state that my participation in this activity is entered Check-in/Register: 8:30am — Invite Only (Includes Lunch) into as a free and voluntary act and is in no way connected with any course Camp Hours: 9:30am-3:00pm (Sat. Only) credit or requirements of the Releasees. I further acknowledge that the Stan BASKETBALL CAMP Holt Basketballl Camp and Coach Holt Basketball Camp is sponsored and $45.00 Camp Fee operated by Stan Holt. This Release contains the entire agreement between the parties hereto and the terms of this Release are contractual and not a Register Online: www.coachholtbasketballcamp.com Our Camp Goals: mere recital. I hereby certify that I am the parent and/or guardian of ______________________, a Minor, and that the foregoing matter has been Or Register via Mail: fully explained to me and I, for and on behalf of said Minor, do hereby release Encourage Teamwork all liability, indemnity, and covenant not to sue as set forth in the body of the Make check or money order payable to: RELEASE above, with the same force and effect as if executed by me. Work Hard and Have Fun!!! Further, as parent and/or legal guardian, I hereby give consent and authorize Coach Holt Basketball Camp Stan Holt Basketball Camp, Coach Holt Basketball Camp, and Langston Mail to: University and Releases to secure emergency medical treatment for Emphasize Positive Attitude Releasor, while said Minor is in attendance at Stan Holt Basketball Camp and Attn: Camp Registrar Coach Holt Basketball Camp conducted by Stan Holt. Releasor further states P.O. Box 3482 Teach Fundamentals that she/he has carefully read the foregoing Medical Release and Edmond, OK Acknowledgement and knows the contents thereof and signs this form as his/ her own free and voluntary act. 73083-3482 Develop Skills Parent Signature _____________________________ Date_____________ Youth Camp: Aug 1-5, 2016 Phone (H)_________________________ (C)_________________________ Elite Camp: Aug 6, 2016 In case of emergency, if parent or guardian cannot be reached contact: www.coachholtbasketballcamp.com ________________________________Telephone_____________________ MEET HEAD MEN’S BASKETBALL COACH Dear Lion Camper, Stan Holt MEET THE CAMP STAFF It is almost time for our basketball Stan Holt and the nationally ranked Lions finished the 2015-2016 camp at Langston! I am excited to season 25-7. The Red River Athletic Conference Tournament send you a personal invitation to join us for a fun, learning experience this Stan Holt — Head Coach Champions had four RRAC All-Conference Players, one NAIA summer. Please accept my personal All-American, and were ranked as high as #11 in the nation, the invitation to attend our tremendous Trey Hendon — Assistant Coach highest national ranking in school history. basketball camp. Participating in our camp is a great, fun way to develop your skills, enhance your basketball Plus... knowledge, and make new friends that enjoy the game of basketball as much as you do! Other Local High School and College Coaches I look forward to seeing you this summer at our wonderful facility, C.F. Gayles Arena! My staff and I are excited to meet Current and Former LU Players you, work with you, help you improve, and have lots of basketball fun! It is going to be a fantastic summer. MEET OUR PROUD SPONSORS Go Lions! With more than 10 years of progressive coaching experience, Coach Holt Holt brings a leadership style that focuses on the entire student- athlete. His emphasis on academics, athletics and 2621 E HIGHWAYIGHWAY 33 character have contributed to the overall success of his former players. Holt and his Lions are the RRAC Tournament GUTHRIE,, OKOK 7304473044 Champions and finished this season ranked #17 in the nation with an overall record of 25-7. Holt cites character Camp Features: development as a crucial component to building a successful 405.260.1702 program. He believes that an emphasis on core values, • Play in historical C.F. Gayles Arena and Marques Haynes providing guidance to promote good decision-making, Court developing a winning attitude and culture, and expecting a laser-like focus on academic achievements is the plan in place • Individual instruction and by Head Coach Stan Holt, his to lead Langston Basketball to its full potential. A determined coaching staff , current and former LU student-athletes. educator, Holt has dedicated his career to offering the highest quality leadership and coaching methods with the goal to • Campers will receive a camp t-shirt and a chance provide student athletes the best opportunity to attain to win many fantastic camp prizes! educational success, character growth, and elite basketball skill development. • Teams will be divided equally. Although competition Holt’s experience includes the high major NCAA Division I can be intense, playing fundamental team basketball level. While on staff at USC, Holt contributed to the is stressed. We will emphasize teamwork, sharing the basket- development of players such as Toronto Raptor’s All-Star ball, playing team defense, and having fun! guard DeMar DeRozan, forward Nikola Vucevic of the Orlando Magic, and Chicago Bulls forward Taj Gibson. • Mystery Guest Speakers will address campers. Speakers Additionally, he helped develop Daniel Hackett, who currently include other college coaches, high school coaches, strength plays for Emporio Armani Milano of the Italian League and and conditioning professionals and/or motivational speakers. former PAC-10 defensive player of the year Marcus Simmons (now playing professionally in Japan). He has worked over 20 national elite basketball camps nationwide including the Kobe Camp is open to any and all entrants (limited only by Bryant Academy, USC Elite Camp and the Nike Phenom 150 number, age, grade level) camp. .