Emergency contact name: **Note: Fee must accompany ______SouthLake Registration form to be accepted** ______Relationship: ______Christian Emergency contact phone: Program for which you are registering: ______Academy ______Other phone: ______Name of Alternate emergency contact name: participant(s):______Presents… ______Address: Relationship: ______Physician’s name: ______City______Zip______Physician’s phone: Date of ______Birth(s):______Insurance carrier: Grade in school: ______Age(s):______Policy/Group Gender: ______#:______Home Phone: ______Other Phone: Shirt Size: ______(Youth) S M L XL Rodney Monroe Parent/Guardian: (Adult) S M L XL 2XL ______Holiday ______Make check payable to: Rodney Monroe Email: ______Basketball Relationship to participant: Camp ______Mail registration and check to: Daytime phone: P.O. Box 1247, Huntersville, NC 28070 ______December 18-22, For more information call or email *Please list any allergies (drugs, plants, Rodney Monroe at (561) 707-7611 2017 animals, etc.), medical conditions, Email: [email protected] restrictions or necessary special accommodations which the instructor or Visit my website at: Ages 6-9, 9am-12pm director should be aware of: RodneyMonroeBasketball.com

______DenverBasketballLeague.com ______Ages 10-14, 1pm-4pm ______**Camp will be held at: ______SouthLake Christian Academy ______13820 Hagers Ferry Road $125/child or Huntersville, NC 28078 $225/two children Parental/Participant Consent Release DAILY ACTIVITIES and Waiver

I (or my child/children) am voluntarily A typical day at camp participating in the program, class or consists of the following: event specified. In return for the opportunity to participate, I voluntarily for myself (or child/children) waive, release, indemnify and hold harmless the Rodney Monroe Basketball Camp, Stretching its employees, and sponsors from any liabilities, claims, damages, injuries, Rodney graduated high school as the losses, and expenses including state of Maryland’s all-time leading reasonable attorneys fees and costs scorer with over 3,000 points. He whatsoever, including those for personal earned a scholarship to North Ball Handling Skills injury, death, or property damage, which Carolina State University, and holds may arise from or in connection with several records including all-time participation in this program, class or leading scorer. He was ACC Player event. of the year in 1991. He broke David Thompson’s school scoring record at Defensive Principals If this registration is for one of my minor NC State, and he’s fifth on the ACC’s children, I herby consent to emergency all-time scoring list with 2,551 career treatment and transportation of my points. In 2002 Rodney was named minor child for any condition that may th to the ACC 50 Anniversary men’s arise from or in connection with basketball team as one of the fifty Shooting Principals participation in the program, class or greatest players in Atlantic Coast event and I shall be responsible for the Conference history. “Fire and Ice” payment of all costs associated with was the popular nickname given to such emergency treatment or Monroe and backcourt teammate transportation. during their years with the Wolfpack. This year Rodney Passing I agree to abide by all Town ordinances was honored as an ACC Basketball and school rules and regulations ad Legend. He was drafted by the understand that the Rodney Monroe and played Basketball has the right to close professionally in Europe 14 seasons. registrations and to change fees and Rebounding/blocking out requirements when necessary. This He has brought his knowledge of the release shall remain in effect until game and desire to work with kids cancelled in writing. together to create an excellent camp that all participants will enjoy. Join ______him as he brings his talent to the Fun and Games area. Sign up before it’s too late! Parent/Guardian Signature Date