Uptown Select - 4th Annual Summer of Separation Elite Shooting Clinics
Athlete Information
Athlete's Name
First Name
Last Name
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
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2015
2014
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2012
2011
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Year
Grade
Gender
Male
Female
Current High School
Position
Level of Play
Please Select
College
Varsity
Junior Varsity
Freshman
Current AAU Team
Referral source
Interested in Playing for Uptown Select?
Yes
No
Email
example@example.com
How many weeks are you signing up for? (Payments Due by August 20th)
1 Week ($125) - Tuesday & Thursday
2 Weeks ($200)- Tuesday & Thursday
1 Day Each Week - ($125)
Other - Please specify in "Other Notes" section
What Sessions do you plan on attending? (Payments Due by August 20th)
Session 1 - Aug 20th & 22nd
Session 1 - Aug 27th & 29th
All Sessions
Do you plan to bring a guest? PLEASE CONFIRM WITH ME FIRST!!! (Guests must not be current or past players, previous attendees, or already invited by Uptown Select)
Guest 1 Name - Take $25 off
Guest 2 Name - Take $50 off
Guest 3 Name
Guest 4 Name
Parent/Guardian Information
Name
First Name
Last Name
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name
First Name
Last Name
Relationship
Please Select
Mother
Father
Grandparent
Aunt
Uncle
Sibling
Babysitter/Nanny
Other
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the athlete prescribed an inhaler? If yes, please explain any instructions.
Other Notes:
Informed Consent and Acknowledgement
I hereby give my approval for my child’s participation in any and all activities prepared by {Organization} during the selected camp. In exchange for the acceptance of said child’s candidacy by {Organization} ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless {Organization} . and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against {Organization} . including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization
As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the {Organization} . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Confirmation
BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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