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SIGNATURE OF PARENT / GUARDIAN____________________________________DATE________________ _____________________________________________________________________________________________.

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Presentation on theme: "SIGNATURE OF PARENT / GUARDIAN____________________________________DATE________________ _____________________________________________________________________________________________."— Presentation transcript:

1 SIGNATURE OF PARENT / GUARDIAN____________________________________DATE________________ _____________________________________________________________________________________________ In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent of (1) the administration of any treatment deemed necessary by the above-named doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. Facts concerning the child’s medical history, including allergies, medications being taken, and any physical impairments to which a physician should be alerted, I have listed below. DOCTOR________________________________________ PHONE (_____) _____________________________ I hereby give consent for the following medical care providers and local hospital to be called: Address______________________________________________________________________________________ Daytime Phone (_______) ______________________________________________________________________ Relationship___________________________________________________________________________________ Name of Relative or Childcare Provider_____________________________________________________________ Daytime Phone (_______) ______________________________________________________________________ Father’s Name_________________________________________________________________________________ Daytime Phone (_______) ______________________________________________________________________ Mother’s Name________________________________________________________________________________ RESIDENTIAL PARENT OR GUARDIAN_________________________________________________________ The purpose of this form is to enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under our authority, when parents or guardians cannot be reached. The 4 day camp will run Mon June 27 -Wed June 29 th 3-6 Grade 1PM-4PM/7-9 Grade 5PM-8PM ______ Small ______ Medium ______ Large ______ X-Large _ Adult T-Shirt Size (check One) Address______________________________________________________________________________________ Contact Person__________________________________ Daytime Phone (_______)_________________________ Height____________________________Weight_____________________________________________________ School_______________________________________________________________________________________ Grade (entering) ___________________________________________ Age________________________________ Phone (_______) _____________________________________________________________________________ City_________________________State___________________Zip________________________ Address ______________________________________________________________________________________ CAMPER’S NAME ___________________________________________________________________________ APPLICATION FORM EMERGENCY MEDICAL FORM Please make checks payable to: Bishop Hartley Women’s Basketball

2 Columbus, Ohio 43227 1285 Zettler Rd. Bishop Hartley High School Bishop Hartley Women’s Basketball Camp Please place Stamp here CAMP COSTS Youth Camp $60 REGISTRATION The registration deadline is June 3 rd, 2016. After the deadline please contact Pat Murphy at 614-237- 5421 for availability. Campers must pay in full at the time of registration on June 27 th. To register by mail, complete the camp application and mail to Bishop Hartley High School. DATES/TIMES Youth Camp Monday, June 27 th through Wednesday, June 29 th Grades 3-6 1:00pm – 4pm Grades 7-9 5:00-8:00 PM FACILITY The Basketball Camp will be held in the Dick Geyer Gymnasium on the campus of Bishop Hartley High School ELIGIBILITY The Youth Camp is open to any athlete entering the 3rd thru 9th grades.` This camp is suitable for athletes of all abilities with and emphasis on FUN! CAMP CONTENT/GOALS The Youth Camp is designed to introduce the young athlete basketball training techniques and skills. Campers will learn techniques to improve their knowledge and skills in the greatest Team game of basketball. The goal of the camp is to help prepare student-athletes to be CHAMPIONS in all walks of life!. REFUND POLICY A full refund, minus a $15 cancellation fee, will be issued for cancellation prior to camp. No refunds will be given once the camp begins regardless of the reason. FOR MORE INFORMATION Contact Donald Dennis @ hartleycoachd@yahoo.comhartleycoachd@yahoo.com

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