LADY PANTHERS BASKETBALL CAMP

CAMP APPLICATION

June 5^th -8^th (Monday-Thursday)

Please Print

Player’s Name: ________________________________________ School: ____________________________________

Address: ________________________________________________________________________________________

City: ________________________________________  State: ____________________ Zip: _____________________

 Phone #: ______________________________________

Grade For next Year:     K       1^st       2^nd      3^rd        4^th         5^th       6^th  

In Case of Emergency Notify: Name: ______________________________ Phone #: ___________________________

T-SHIRT SIZE: (CHECK ONE)

ADULT

SMALL: _______

MED: _______

LARGE: ______

X-LARGE: ____

XX-LARGE: _______

YOUTH

SMALL: _______

MED: _______

LARGE: ______

CAMP COST: $25.00         

MAKE CHECK PAYABLE TO:                                              RHS GIRLS BASKETBALL

MAIL/BRING PAYMENT AND APPLICATION TO:             RUSSELLVILLE JR/SR HIGH SCHOOL

                                                                                              C/O COACH CALVIN HEAD

                                                                                              1101 W 9^TH ST

                                                                                              RUSSELLVILLE, KY 42276

CAMP LOCATION:                                                               RUSSELLVILLE MIDDLE SCHOOL GYM

MEDICAL INSURANCE COMPANY / POLICY NUMBER: __________________________________________________

I, the undersigned parent / guardian, understand that the applicant will be engaging in physical activity during the camp.  This contains an inherent risk of physical injury and the undersigned assumes this risk.  I release the Russellville Lady Panther 2017 Basketball Camp, its officers, directors, agents and employees from any and all liability for personal injury arising out of the applicant’s participation in the basketball camp.  I hereby grant permission for my child to attend the Russellville Lady Panther 2017 Basketball Camp and to receive treatment by a licensed physician or camp instructor in the event of any injury, accident, illness or other mishap.

___________________________________________________________________________________________________________ PARENT / GUARDIAN SIGNATURE                                                                                           DATE

**Please note any specific medical conditions or allergies to medications**