K-3rd BASKETBALL CAMP
JUNE 13-15, 2022 | 1:00pm-2:30pm | VHS GYM | $60 Registration Fee | Includes All Camp Instruction, Camp T-shirt, and Basketball
PLAYER REGISTRATION
Please complete all sections below.
Player 1 Name
*
First Name
Last Name
Grade Level of Participant
*
Please Select
Kindergarten
1st
2nd
3rd
As of 2022/2023 school year
T-Shirt Size
*
Please Select
Youth Small
Youth Medium
Youth Large
Youth X-Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
School Your Child Attends
*
Please Select
Central
Cooks Corners
Flint Lake
Heavilin
Memorial
Northview
Parkview
TJE
St. Paul
Immanuel Lutheran
Other
As of 2022/2023 school year
Does your child(s) have any allergies, chronic illness, mental illness, or medical conditions that would limit high level activity?
*
Yes
No
If you answered "Yes" to the question above, please explain here:
Player 2 Name (if registering more than 1 camper)
First Name
Last Name
Grade Level of Player 2
Please Select
Kindergarten
1st
2nd
3rd
As of NEXT school year (2022/2023)
T-Shirt Size of Player 2
Please Select
Youth Small
Youth Medium
Youth Large
Youth X-Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Adult XX-Large
School of Player 2
Please Select
Central
Cooks Corners
Flint Lake
Heavilin
Memorial
Northview
Parkview
TJE
St. Paul
Immanuel Lutheran
Other
Does your child(s) have any allergies, chronic illness, mental illness, or medical conditions that would limit high level activity?
Yes
No
If you answered "Yes" to the question above, please explain here:
GUARDIAN INFORMATION
Please complete all sections below.
Guardian / Parent Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
*
E-mail
*
example@example.com
Emergency Contact & Health Insurance Information
Emergency Contact's Name
*
First Name
Last Name
Relationship
*
Please Select
Mother
Father
Grandparent
Aunt
Uncle
Sibling
Babysitter/Nanny
Other
Phone Number
*
Insurance Carrier
*
Insurance Policy Holders Name
*
First Name
Last Name
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RELEASES
Please complete all sections below.
Permission For Emergency Medical Treatment
As the legal parent or guardian, in the event of illness or accident, I give consent for the Valparaiso Basketball Skills Academy, LLC, members of the Valparaiso High School Basketball Coaching Staff to secure any and all necessary emergency medical care for my child. The undersigned gives permission to the Valparaiso Basketball Skills Academy, LLC,., its owners and operators and members of the Valparaiso High School Basketball Coaching staff to seek medical treatment for the participant in the event they are not able to reach a parent or guardian. I request that my child be transported to the Hospital in the event of an emergency. I hereby declare we have listed any physical/mental problems, restrictions, or conditions and/or declare the participant to be in good enough physical and mental health to participate in basketball practice and games.
I have read and agree to the above conditions of the Permission For Emergency Medical Treatment:
*
Yes
Release of Liability
As the legal parent or guardian, I release and hold harmless the Valparaiso Basketball Skills Academy, LLC,, its owners and operators, members of the Valparaiso High School Basketball Coaching Staff and Players, and the Valparaiso Community School Corporation from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of the Valparaiso Basketball Skills Academy, LLC, its owners and operators or in route to or from any of said premises.
I have read and agree to the above conditions of the Release of Liability
*
Yes
Covid Policy (only as applicable): PLAYERS WILL BE REQUIRED TO WEAR MASKS IN ALL SITUATIONS THAT PHYSICAL ACTIVITY IS NOT OCCURING INCLUDING ENTERING AND LEAVING THE BUILDING. PLAYERS NEED TO HAVE MASKS ON WHEN THEY ARRIVE, DURING BREAKS, AND ANYTIME REQUESTED BY THE STAFF. ANY PLAYER BEING QUARANTINED BY VCS OR OTHER HEALTH AGENCIES MAY NOT PARTICIPATE. PARENTS WILL NOTIFY THE VALPARAISO BASKETBALL SKILLS ACADEMY IF THEY ARE NOTIFIED THAT THEIR CHILD HAS BEEN QUARANTINED. PARTICIPANTS MAY RETURN TO PARTICIPATE UPON RELEASE FROM VCS AFTER THEIR QUARANTINE DATE HAS EXPIRED. DUE TO INITIAL OPERATIONAL COST INCURED BY THE VALPARAISO BASKETBALL SKILLS ACADEMY, REFUNDS DUE TO QUARANTINE WILL ONLY BE RECONIZED FROM VCS ISSUED SITUATIONS. DUE TO OPERATIONAL COSTS REFUNDS WILL BE PRORATED MINUS THE COST INCURED FROM PLAYER INSURANCE, FACILITY FEES, AND SUPERVISION. SESSION DATES SUBJECT TO CHANGE AND CANCELATION DUE TO CIRCUMSTANCES BEYOND OUR CONTROL. ANY SPECTATORS ATTENDING PRACTICE OR GAMES MUST HAVE A MASK ON WHILE THEY ARE IN ATTENDANCE THAT COVERS THEIR NOSE AND MOUTH.
I have read and agree to the above conditions of the Covid Policy
*
Yes
Social Media Release:
As the legal parent or guardian, I grant permission for the Valparaiso Basketball Skills Academy, LLC to utilize my player's photo or video footage to promote the program using various social media outlets.
I have read and agree to the above conditions of the Social Media Release
*
Yes
Is there anything else you'd like to communicate as it relates to this Camp registration?
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Confirmation E-mail
*
example@example.com
If you have any questions, please contact Coach Coolman: bcoolman@valpo.k12.in.us NOTE** Discounted price available for students that qualify for Free and Reduced Lunch. Please Contact Coach Coolman for details.
CAMP PAYMENT HERE
*
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PRICE PER PLAYER
Valparaiso Basketball Camp K-3rd 2022
$
60.00
Number of Players
1
2
Item subtotal:
$
0.00
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