Registration Form Mien’s Basketball Office Mien’s Name _______________________________________________________________ Springfield, MO 65897 901 S. National Address_____________________________________ City _____________________ State ____________________________ Zip ________________________________ Parent’s Name ________________________________________________________ 2 Home Phone ( ) ____________________ Work Phone ( ) _______________ Cell Phone ( ) _____________________________________________________ Child’s Age ______________ Height _____________ Grade Next Fall ____________ 0 Name of School _______________________________________________________ Coach’s Name ________________________________________________________ Coach’s Phone ________________________________________________________ 1 INDICATE WHICH CAMP YOU WILL ATTEND ___Shootout ___ Varsity ____JV ____Junior High............June 18-19 (RES $125) 0 ___Shootout ___ Varsity ____JV ____Junior High................... (COM Team $500) ___ Individual Day Camp………………..June 14-17………………………….($200) ___ Offensive Skills Camp……………..June 5 …………………………………($85) ___ Father/ Son Camp………………….June 26……………………….. (1 son $100) ___ Father / Son Camp…………………June 26…………………….... (2 sons $110) PARENTS’ RELEASE & INDEMNITY AGREEMENT We, (or) I hereby request you accept the application for enrollment of _______________________________ In the 2010 Cuonzo Martin Basketball Camp during the dates set forth in this application, and in consideration of your acceptance of the application, we (or I) (whether one or more) hereby release the Cuonzo Martin Basketball Camp and the Board of Governors of MSU and all their employees and agents Offensive Skills Camp from all claims on account of any injuries which may be sustained by our (or my) minor son while attending the 2010 Cuonzo Martin Basketball Camp and its employees and June 5 agents for any claim which may hereafter be presented by our (or my) minor son as result of any such injury. I (or we) authorize and provide consent for licensed medical providers or MSU Taylor Health Center physicians and staff to administer any medi- Individual Day Camp cal procedure or treatment which may be deemed medically advisable by the attending physician including diagnostic testing and examination should my child become injured June 14-17 or sick during this camp. Parent’s/Legal Guardian Signature _________________________________________ Varsity/ JV/ Junior High Total Enclosed $________________ Shootout A $100 nonrefundable deposit is required per camp. June 18-19 Return this form and check payable to: Father/ Son Camp Missouri State Men’s Basketball June 26 MBB Office Cuonzo Martin Basketball Camps 901 S. National Ave, Springfield MO 65897 Offensive Skills Camp Father/ Son Camp Camp Information June 5 June 26 LOCATION: The 2010 Cuonzo Martin Basketball Camps will be held on (Grades 7-12) (Sons entering 1st-6th Grade) campus. Housing will be in air-conditioned dorms. All activity will be This one day camp is designed to enhance each player’s offensive This one day camp is designed to allow father and son to have a held at air conditioned Hammons Student Center, JQH Arena, McDonald skills. All aspects of the offensive game will be covered and taught great time learning the game of basketball. Unique features of the Arena, and Greenwood High School. Dorms will be well-supervised in detail. Come learn the necessary fundamentals and skills that will camp include: lectures given by the Missouri State basketball staff, with counselors, and campers will not be permitted to leave without take your offensive game to a new level. MSU coaches and players opportunities for father and son to share in the game of basketball permission. will be demonstrating and present throughout the camp. Campers and the game of life, and bonding experiences for both father and CAMP HOURS: Shootouts will begin immediately after check in. will receive a T-Shirt and MSU basketball which is included in the son on and off the court. Both father and son will receive a camp This could vary slightly depending on the number of teams. They will camp fee. Lunch will be provided. T-shirt and will be provided lunch. MSU players will be present conclude in the evening with the conclusion of each team’s last game. throughout the camp along with autograph opportunities Check In: 8:00-9:00 am, Check Out: 4:00 pm REGISTRATION: Check in hours are listed on the brochure and will take Camp Cost: $85 Check In: 8:00-9:00 am, Check Out: 4:00 pm place in the South Court of Hammons Student Center. Camp Cost: $100 for 1 son, $110 for 2 sons MEALS: For those campers staying in the dorms, unlimited food is Individual Day Camp offered in the dining centers. Meals for the Shootout will begin with dinner the first day of camp. June 14-17 Cuonzo Martin - Director (Grades 1st-8th) WHAT TO BRING: Each overnight camper will be expected to bring This instructional camp is for players entering the 1st through the their own linens (twin size bed), pillow, toiletry items, towels, etc., gym 8th grade. Campers will be grouped by age and ability. All aspects shoes, t shirts, shorts, and several pairs of socks. Small coolers, fans of the game of basketball will be covered including 3 on 3 and 5 on and alarm clocks are allowed in the dorms. Leave valuables at home 5 games for friends and family to see. Campers will receive a T-shirt as the camp is not responsible for lost items. and MSU basketball which is included in the camp fee. Lunch will CANCELLATIONS: Your $100 deposit less a $25 administration fee also be provided each day of camp. MSU players will be present will be refunded if your enrollment is cancelled prior to May 17, 2010. throughout the camp. After May 17, refund will be given only for medical reasons when accompanied by a letter from your physician. If a camper must leave Daily Check In: 9:00 am, Daily Check Out: 4:00 pm during the week, the refund will be prorated. No refunds will be given to Camp Cost: $200 campers who leave the camp voluntarily during the week. EXAM & HEALTH PHYSICAL CARE: We require a physical examination Varsity/JV/ Junior High Shootout with your application. The physician ensures us that each camper is in top physical condition and the form (obtain from your physician or June 18-19 school) must be signed within the current year. School physicals are Come visit the campus of Missouri State University for a weekend acceptable if they have been dated within the current school year. We shootout. There will be three separate divisions: Varsity, JV, and recommend that each camper be in excellent condition. This not only prevents injuries, but also makes the learning process much easier. Junior High teams. These competitive sessions will allow your • 2nd Season as Head Coach at Missouri State University teams to work together and strive for a great season ahead. All • 8 seasons as assistant coach at Purdue (2000-2008) INSURANCE: The Cuonzo Martin Basketball Camps has acquired games will be played on the campus of Missouri State University insurance to provide expenses incurred as a direct result of camp and the Bears coaching staff and players will be present throughout • 3 time captain as a player at Purdue (93, 94, 95) participation up to $10,000. This coverage is secondary coverage the weekend. Teams are guaranteed 6-8 games and will be officiated paying medical expenses incurred up to $10,000 after your insurance • 11th on Purdue’s school career scoring list by certified referees. has paid its limits. • Led the Big Ten Conference in 3 pt % during his senior year Contact Information: Check In: 10 am- Noon on June 18 • 2 Big Ten Conference Championships as a player 417-836-5250 (Brenda Essary) Camp Cost: $500 per team for commuters (no meals or rooms provided) OR $125 per player for resident teams (3 meals and 1 • Played in the NBA for the Milwaukee Bucks and Vancouver Grizzlies. 417-836-4474 (Coach Fisher- Shootout) night stay provided) Also played in the CBA and Europe Toll Free 866-767-2327 • www.missouristatebears.com Camps are open to any and all entrants (limited only by number, age, grade and/or gender).