Summer Basketball Medical and Liability Release Form

Basketball Camp Registration & Medical Release Form

Each student must fill out the information below completely. This form will be kept on file for one (1) year as a medical release. If your medical or insurance information changes, please contact the front office or submit another online form to update your information.
Date
July 14-18, 2025

Time:
K-4th grade 8 am - 12 pm
5th - 12th grade 12 pm - 4 pm

What to Bring:
- Come dressed in athletic wear
- Refillable water bottle
- Packed Lunch
- Optional: Small gym bag/backpack for a change of clothing
Student's Name*

First NameLast Name
Gender*

FemaleMale
Date of Birth*

MonthDayYear
Date
Age*
Grade*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List any Allergies your Child has:
Any medication needed, including but not limited too, ibprofen, tylenol, allergy medicine and even menthol cough drops, require the Medication Administration Form to be filled out by a medical provider. All medication will be held by the school office and be administered by a member who has been gone through the Medication Administration Training.
Parent / Guardian Name*

First NameLast Name
Cell Phone Number*
Work Phone Number
Home Phone Number
Emergency Contact (If parents cannot be contacted)*

First NameLast Name
Emergency Contact Phone Number*
Please list who has permission to pick up your child
First and Last Name
First and Last Name
First and Last Name
Insurance Information
Carrier Name
Policy Number
Policy Holder
First and Last name
RELEASE OF LIABILITY

I hereby give my permission, my child, to participate in an activity organized by Frederick Adventist Academy. I hereby release, hold harmless and absolve Frederick Adventist Academy, their officers, staff, sponsors, vendors and all others who have participated in the planning, organizing, and implementing of the activity, be the individuals or organization, from responsibility and liability for any illness, injury, misadventure, harm, loss or inconvenience suffered or sustained as a result of the participation in the activity. I understand that in the event I or my child requires medical treatment while engaged in the activity, reasonable efforts will be made to contact my designated emergency contacts; however, if they cannot be reached, I hereby consent and give my permission to the Frederick Adventist Academy staff or any adult counselor acting on behalf of Frederick Adventist Academy with respect to the activity, to consent to any X-ray examination, medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate} licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all my child's medical allergies, medications being taken, medical problems and other pertinent information.
Signature*

Powered by Jotform SignClear
Parent / Guardian
Submitted Date*

MonthDayYear
Date
Photo Release

I hereby grant Frederick Adventist Academy the unconditional right to use my child's name, voice, photographic likeness of my child in connection with any of the audio video production, articles, website materials or press releases, but not as an endorsement.
Do you agree or disagree?*
Payment

Cost: $250
Choose 1 method

FACTS ( by choosing this method, I give permission for my FACTS account to be charged - enrolled students at FAA)Cash or Check (Please drop off payment at the school office during summer hours)Credit Card (Please follow the link to Zeffy. Choose 0% when asked for donation)Multi-child discount needed (please email principal@frederickadventistacademy.org)
Zeffy link for credit card payments:

https://www.zeffy.com/ticketing/summer-camp--2025-15
Should be Empty:

Basketball Camp Registration & Medical Release Form

Insurance Information

RELEASE OF LIABILITY

Photo Release

Payment