To register, return this form or contact: Coach Dee Vick at (434) 223-6160

July 20-24 Week Long Instructional Camp
$100 Deposit to reserve a spot

Name:                ______________________________________________________
Address:             ______________________________________________________
City/State/Zip:     ______________________________________________________

Home Phone:     (______)________________________________________________
Parent/Guardian: _______________________________________________________

Business Phone:  (______)________________________________________________

Grade Entering Fall of 2008: ______________________________________________

Day Camper ____________or Boarder ___________

Roommate Request:    __________________________________________________

Age in July 2008:   _____________ Height: _____________ Weight: ______________

T-Shirt Size  (S)   (M)   (L)   (XL)   Adult

Make Checks payable to Hampden-Sydney Basketball Camp. Camp deposit must accompany this form. Camp deposit is non-refundable.

Mail To:
   Coach Dee Vick
   Hampden-Sydney Basketball Camp
   P.O. Box 698
   Hampden-Sydney, VA 23943
 

Medical Form

Name:      ___________________________________________________________

Address:   ___________________________________________________________
  __________________________________________________________________
  __________________________________________________________________

Phone #:   ___________________________________________________________

Medical Information (To be completed and signed by camper's physician)

 _____________________________________ (name) is physically able to participate fully in athletic activity at Hampden-Sydney Basketball camp. His/Her physical condition is
(Good)  (Average)  (Poor).

He/She has the following special conditions to be aware of:
 __________________________________________________________________

He/She must take the following medications:  __________________________________________________________________

He/She must have the following routine in his diet or activity: __________________________________________________________________

Allergies: ___________________________________________________________

Additional comments or special needs: _____________________________________
  __________________________________________________________________

Doctor's Signature: _________________________________ Date: ______________

Parental Permission

Swimming:

 _____________________________________ (name) does / does not have my permission to swim at the Hampden-Sydney pool under supervised conditions.  His / Her swimming ability is (Good)  (Average)  (Poor).

Parent Signature: __________________________________ Date: ______________

Emergency Care:

I hereby authorize the staff of Hampden-Sydney Basketball camp to act in my behalf in the event that I cannot be reached in an emergency.  I hereby waive and release the H-SC Basketball Camp from any and all liability for injuries or illness sustained during any session. 

Parent Signature: __________________________________ Date: ______________