Basketball Camp Registration – Hope On The Hill

Registrant Name:

Camp Goer Name

Day Phone

Email Address

Date of Birth

Address

State

City

Zip

Shirt size

Does your camper have any physical or medical conditions that we should know about?

If so, what is the condition and what is the current treatment?

Does your camper have any allergies? If so, what is your camper allergic to?

Is your camper allergic to any medication? If yes, list the medications your camper is allergic to:

Is your camper currently taking any medication? If so, please list the reason, medication and dosage.

Do you want these medications to be administered by camp personnel? If so, please list how and when:

Do you give the hope on the hill track camp medical training staff permission to provide your camper with medication?

Medical Insurance Company

Policy Holder Name

Insurance Policy Number

Policy Holder’s Daye of Birth:

Group Number (If applicable)

Emergency Contact Name:

Emergency Contact Relationship

Emergency Contact Phone Number:

I/We grant permission for a photo/page that includes my camper without any other personal identifiers to be published on The Dwight D. and Sheryl H. Howard Foundation’s public internet site:

Do you agree to the terms of our risk and release policy statement as seen below? Electronic Signature:

Waiver of Liability I, being a parent or legal guardian of the child requesting camp admittance, do hereby affirm that the applicant is in good health, and suffers from no illness, disability or condition that limits physical activity or requires the taking of medication, unless such limitation and/or medication is specifically set out in the medical portion of this registration. If there is such a condition or medication, this application may be rejected by the Camp if the Camp determines that there is a concern about the applicant's well-being at Camp, in which case all deposits will be refunded. If this application is not rejected, the Camp will use best efforts to limit activity and to help with medication, but the Camp does not assume responsibility for failure of all medication to be administered, or for injury or illness related to the taking (or failure to take) medication or from activities engaged in by the applicant that result in injury or illness. As used in this paragraph,