BASKETBALL CAMP

GAME SPEED

GAME SPEED

GAME SPEED

GAME SPEED

GAME SPEED

Registration Form

Student's Name__________________________________________

Home Phone___________________Other Phone________________

Emergency Contact Name__________________Phone___________

Date of Birth_______Grade/Fall2011___School/Fall 2011_________

Please list any medications your child is taking at this time:

_______________________________________________________

_______________________________________________________

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Date of last physical_____Immunization Completed  YES___  NO___

If no, why? _____________________________________________

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I certify that this child is physically fit for participate in the

GAME SPEED BASKETBALL CAMP without restrictions

Signature of Physician__________________________Date_____

Parental Waiver and Consent

As the parent/guardian of the child named above, I hereby give my consent and approval for my child to participate in the GAME SPEED BASKETBALL CAMP. I certify that my child is in good physical health and has my permission to participate. My child has no previous sickness, illness, disease, or bodily injury which is contradictory to participation. I understand that participation in camp may involve physical contact and there are certain risks of injury inherent in the practices and play of any sport and I am willing to assume these risks on behalf of my child. I understand that I am fully responsible for any and all costs regarding medical attention and treatment of my child.

I hereby give my consent for medical treatment deemed necessary by medical personnel designated by GAME SPEED BASKETBALL INC. and/or for transportation to a hospital emergency room for treatment of any illness or injury resulting from his/her athletic participation. In addition to giving my consent for my child to participate, I do hereby waive, release, and hold harmless GAME SPEED BASKETBALL INC and ST. ANTHONY's HIGH SCHOOL, and their officers, coaches, and representatives for any injury that may be suffered by my child in the normal course of participation and the activities incidental to it.

PARENT/GUARDIAN'S SIGNATURE________________________________DATE_______