Jessie Evans Basketball Camps

2006

_____ Session I: June 19-22

_____Session II: July 31 - August 3

Who: Boys and Girls ages 6-18

Cost: $195

Name: ________________________________Phone_____________________________

Address:____________________________________City/Zip: ______________________________

Age: ______ DOB:________ Grade: ________ School: ___________________

School/Playing Experience:__________________________________________________

Please note any medical condition:___________________________________

Insurance Company:______________________Policy # ____________________

Doctor's Name and #:_________________________________________________

Emergency Contact:___________________________________________________ 

I hereby authorize the staff and USF/Jessie Evans Basketball Camps to act for me

according to their best judgment in any emergency requiring medical

attention and hereby waive and release USF from any

injuries or illness while at the clinics. The clinic staff has my permission to

seek any emergency treatment necessary for my child while in attendance at

the clinic named above.

Parent/Guardian Signature: ________________________Date:_________________

print this form, fill out, with a check in the amount of ______ payable to Jessie Evans Basketball Camp send to:

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