Shannon Dowell Youth Camp Registration Form

Shannon Dowell Youth Camp Registration Form

Shannon Dowell Youth Camp Registration Form

These forms are required for your children (girls and boys) to attend camp on August 7th and 8th at Pontiac Junior High School. Contact Shannon Dowell at simoneeliteathleticsllc@gmail.com
Camper's Information
Member ID
Camper Name
Nickname
Date of Birth

MonthDayYear
Age
Grade
T-Shirt Size

Parents' Information

Parent/Guardian 1
Parent/Guardian 1

First NameLast Name
Relationship to Child
E-mail
example@example.com
Cell Phone
Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Work/School Name
Or enter N/A if not applicable
Parent's Work/School Phone
Format: (000) 000-0000.
Parent's Work/School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where would you like to be reached while your child is at camp?
Liability Wavier

Simone Elite Athletics Basketball Camp Waiver and Release Form
Acknowledgment and Assumption of Risk:

I, the undersigned parent or legal guardian of the participant named below (the “Participant”), hereby give permission for my child to participate in the Simone Elite Athletics Youth Basketball Camp.

I understand that participation in basketball and related athletic activities carries inherent risks, including but not limited to: slips, falls, physical contact with other participants, collisions, injuries caused by improper use of equipment, dehydration, sprains, fractures, concussions, and other potentially serious or life-threatening injuries.

I understand that Shannon Dowell, Simone Elite Athletics, Pontiac Junior High School, its staff, volunteers, and any affiliates, sponsors, and agents (collectively the “Released Parties”) will not be held responsible for any injuries, illnesses (including COVID-19), property damage, or other losses sustained by my child or any family member during the camp.

Medical Authorization:

In the event of a medical emergency, I authorize the staff of Simone Elite Athletics and/or the Pontiac Junior High School to obtain emergency medical treatment for my child. I understand that reasonable efforts will be made to contact me immediately. I agree to be financially responsible for any medical treatment or services provided.

I certify that my child is physically fit and able to participate fully in the activities of this camp. I have disclosed all relevant medical conditions to the staff.

I have read and fully understand this waiver. I understand that by signing this document, I am giving up substantial rights, including the right to sue. I sign this form voluntarily and of my own free will.
By signing below, I voluntarily assume full responsibility for any and all risks of loss, damage, or injury that may be sustained by my child or myself during the camp. I, on behalf of myself and my child, hereby release and hold harmless Shannon Dowell, Simone Elite Athletics, Pontiac Junior High School, their staff, volunteers, employees, officers, and agents from any and all liability, claims, demands, actions, or causes of action whatsoever, whether known or unknown, arising out of participation in the camp.
Media Release

Emergency Contacts/Authorized Pickup

List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Heading

Emergency Contact #1
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Relationship to Child

Payment and Statement of Understanding
Camp Session Selection
Which day will you attend?

Payment

USDDescription

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Total Amount
I give permission for Simone Elite Athletics, its staff, representatives, and volunteers to secure emergency medical transportation and treatment for my child in the event of an illness or injury that requires immediate attention during the Simone Elite Athletics Youth Basketball Camp. I understand that the emergency medical service provider will determine the most appropriate facility for treatment based on the situation. I acknowledge that I am responsible for any medical expenses incurred as a result of such treatment and transportation.
Type first and last name above to consent
This form, once completed and signed by the parent or legal guardian, must be reviewed for accuracy and completeness by the camp administrator or authorized designee prior to the child participating in the Simone Elite Athletics Youth Basketball Camp. Following the initial review, if any changes or updates are made, the parent/guardian must review and initial the form accordingly. This form must also be reviewed, initialed, and dated by both the parent/guardian and the camp administrator or designee at least annually or prior to each new session of participation.
Type first and last name above to consent
Acknowledgement of Policies and Procedures I have reviewed and received a copy of the center's policies and procedures/handbook.
Sign Document
Date Signed

MonthDayYear
Camp Director Name and Contact Info
Should be Empty: