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Overnight Camp Registration

Register by April 15 for automatic $15 early-registration discount!

First name:      Last name:
Mailing address line 1 (required):
Mailing address line 2 (optional):
City:      State/province:      Zip/postal code:
Country (if not U.S.):
Primary phone number:
Secondary phone number:
E-mail address:

School name:      Grade (before camp):
     Birthdate: / /
Height: ft. in.      T-shirt size:
Date of last tetanus shot: / /

Session preferred:     
Group name (for group discount):
Preferred roommate(s) (all requests must match):

How did you learn about our camp?
Promo code (if provided by camp):
Optional transportation to camp:
Optional transportation from camp:

Parent/legal guardian
Name:
Phone:

Emergency contact (other than parent)
Name:
Phone:
Relationship to camper:

Insurance information
Company:
Policy holder:
Policy number:
Group number:

Physician
Physican name:
Physician phone:

Medical history (check all that apply)
Allergy, food or other  Asthma  Diabetes  Other chronic health condition
Seizure  Behavioral issues  Significant mental health condition
Prescription medicine (see Medication section below)  Other medication
Explain if you checked any boxes above:
Medication
If your child will be taking medication at camp, you must fill out the portion below. Prescription medication may only be given if it is in the original container from the pharmacy with the FULL label still on it. If your medication came with an outer container (box, etc.) that has the label, this container MUST be brought to camp. Campers may not keep medication of any kind with them. All medication must be turned in to the athletic trainers upon arrival.
Medication Reason for medication Dosage Taken how many times per day and at what times Camper has taken at least one dose prior to camp (required)
The above-listed medication(s) may be given to the above-named camper.

Non-prescription medication consent
I give permission for my child to take more than one dose of over-counter medication(s) (pain reliever, antacid, cough meds, etc.). The camp stocks these medications so there is no need to send them to camp.

Consent to release
I hereby give permission to Morgan Wootten, Inc., t/a Coach Wootten's Basketball Camp, its officers, employees, agents, trainers and staff members to take whatever action is necessary for the health and welfare of my child including consenting on my behalf to any and all medical treatment, procedures, operations and/or hospitalizations and I further agree to hold them harmless and indemnify them for all medical bills incurred for the treatment of my child. I understand that basketball is a very physical sport which can result in serious injury. I hold Morgan Wootten, Inc., t/a Coach Wootten's Basketball Camp, its officers, employees, agents, trainers and staff members harmless and hereby release them from liability for any injury to my child while attending the camp. I understand that my child will swim at camp. I give my consent and permission for my child to do so.

A $250 deposit is required for each application. The deposit is refundable until April 15, 2012. You can pay the deposit with Visa or MasterCard.



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