Basketball Camp

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There is no youth basketball camp scheduled at this time.

DUMFRIES YOUTH CENTER
BASKETBALL CAMP APPLICATION

(separate application required for each child)

Child's Name:________________________________________ DOB:___/___/____

Age:____ Sex:_______

Address:___________________________________________

City:___________________________ State:____ Zip: _______

Phone (H):___________________ Phone (W): ____________________
Phone (C): ____________________

Email: ____________________________________________

Any existing health problems/medications? ____________________________________________________

Are the child's immunizations up to date? ( ) YES ( ) NO

Does your child have any allergies? ( ) YES ( ) NO if yes, please list: _______________________________

____________________________________________________

EMERGENCY INFORMATION

In case of emergency please contact the following:

If there is a current court order in place which defines or restricts visitation or accessibility by either parent, guardian or any other person, a copy of the court order is required with this application.

MOTHER:________________________________________
Phone #_________________________________

FATHER:_________________________________________
Phone #________________________________

GUARDIAN/RELATIVE/FRIEND:______________________
Phone #_________________________________

HEALTH COVERAGE________________________________ID#_______________

PHYSICIAN:______________________________________
Phone #_________________________________

EMERGENCY ASSISTANCE/TRANSPORTATION

I____________________________________________ hereby authorize Dumfries Youth Center personnel and/or volunteers to secure emergency care and transportation for above child. This form does not authorize or guarantee treatment upon arrival at the hospital.

I ____________________________________ do not grant permission for my child to be treated by emergency personnel or transported to the hospital for emergency medical treatment. In the event of illness/ emergency, I wish for the following measures to be taken:

____________________________________________________________________

_______________________________________________________

By signing and returning this application, the undersigned agrees to hold harmless Grace Church and/or Dumfries Youth Center for any injury or accident incurred while participating in camp. I agree to promptly notify Dumfries Youth Center personnel and/or volunteers of any changes to above information. I acknowledge that this form is legally binding and so by signing it that all information is accurate.

PARENT'S SIGNATURE:____________________________________________ DATE:_________________

EXTERNAL PREPARATIONS

I hereby give Dumfries Youth Center personnel and/or volunteers permission to apply one or more of the following external preparations in accordance with the directions for use on the container.

( ) Baby wipes ( ) Band-aids ( ) Neosporin ( ) First-aid Spray ( ) Sunscreen ( ) Insect Repellent

( ) Hand Sanitizer ( ) Other: _______________________________________

PARENT'S SIGNATURE:____________________________________________ DATE:_________________

Cost of basketball camp is $40/4 weeks.

Payment is due with the completed application. Cash and checks accepted.

Please bring a water bottle with your child to basketball camp.

Ages	Camp Dates
10-12	Monday, July 13, July 20, July 27 and August 3
7-9	Tuesday, July 14, July 21, July 28 and August 4
4-6	Thursday, July 16, July 23, July 30 and August 6