Summer Camp Detailed Registration Form

SOUTHWESTERN COLLEGE

BuilderVB Summer Camp Sign-Up
CAMPER REGISTRATION
Campers Name

First NameLast Name
Gender

MaleFemale
Birth Date

MonthDayYear
T-Shirt Size

SMALLMEDIUMLARGEXLARGE2X LARGE
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Camper Cell Phone #
CAMPER INFORMATION
Grade (Fall 2023)
School
Height
Primary Position
Secondary Position
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
SELECT YOUR CAMPS*

July 10th Mighty Moundbuilders Camp (3rd-5th grade) 8:30AM - 10:00AM $25 *Free T-shirtJuly 10th Mighty Moundbuilders Camp (6th-9th grade) 10:30AM - 12:00PM $25 *Free T-shirtJuly 11th Elite Skills Camp (9-12th grade) 8:30AM-12:00PM $25July 12th Elite Skills Camp (9-12th grade) 8:30AM-12:00PM $25July 13th Elite Skills Camp (9-12th grade) 8:30AM-12:00PM $25July 11-13th Elite Skills Camp (9-12th grade) 8:30AM-12:00PM $75 *Free T-shirtJuly 10-13th Fast Fours: (6-12th +) 6:00PM-8:00PM $5/night
Emergency Information (Please attach any and all pertinent medical information we should be aware of and complete the waiver below)
Emergency Contact's Name

First NameLast Name
Relationship
Emergency Phone Number
Alt. Phone Number
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.
Insurance Company Name
Address of Insurance Company *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Policy Number
WAIVER & RELEASE AGREEMENT

UPON ACCEPTANCE OF THIS APPLICATION, I HEREBY WAIVE AND RELEASE ANY AND ALL RIGHTS AND CLAIMS FOR DAMAGES I MAY HAVE AGAINST THE BOARD OF TRUSTEES OF SOUTHWESTERN COLLEGE AND ITS EMPLOYEES, AS WELL AS THE CAMP'S DIRECTOR AND ITS STAFF, ON ACCOUNT OF ANY INJURIES OR ILLNESS SUSTAINED BY MY CHILD WHILE ATTENDING A BUILDERVB VOLLEYBALL CAMP. I AUTHORIZE THE DIRECTOR OF THE CAMP OR HIS/HER DESIGNEE TO SELECT HOSPITAL FACILITIES AND/OR PHYSICIAN OF HIS CHOICE AND AUTHORIZE TREATMENT ON AN EMERGENCY BASIS IN THE EVENT SUCH TREATMENT BECOMES NECESSARY AS A RESULT OF PARTICIPATION IN KWU VOLLEYBALL CAMPS OR FROM STAYING ON THE CAMPUS OF SOUTHWESTERN COLLEGE.

MEDICAL INSURANCE: ALL CAMPERS WILL BE REQUIRED TO HAVE A SIGNED WAIVER AND RELEASE AGREEMENT ON FILE BEFORE PARTICIPATING. ALL PARTICIPANTS SHOULD BE COVERED BY PERSONAL MEDICAL INSURANCE. EACH CAMPER IS ASKED TO PROVIDE THE COMPANY NAME, ADDRESS, AND POLICY NUMBER AND OWNER. THE ACCIDENT INSURANCE PROVIDED BY THE CAMP IS ON AN EXCESS BASIS.
Signature

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Date

MonthDayYear
Date
Medical Information Upload
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.
Please verify that you are human*
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SOUTHWESTERN COLLEGE