Clone of Sign Up Deltona KROCZ Form

Deltona Krocz Developmental

AAU Basketball

Boys & Girls: 8-16 yo.

Sign Up: FREE

Camper Information

Name*

First NameLast Name

Age / D.O.B*

Jersey / Short Size*

Guardian / Parents Names*

First NameLast Name

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Home Phone*

Format: (000) 000-0000.

Cell Phone

Format: (000) 000-0000.

E-mail*

example@example.com

Important Notes

Thiis is a basketball camp. Parents are to ptovide lunch/refreshments for their kids/campers. I, coach Raphael aka Deltona Krocz Camp Basketball is not to be held responsible for any injuries to your child and to include death.

Please pick up at or by 3:00 pm.

· The league organizers reserve the right to form the teams to ensure the talents of all teams are balanced.

· Sign Up fee is $10 per camper payable thru cash app or zelle.

Camp fee is $50 and payable before start of camp.

. Fees are non-refundable...for any reasons. All payments should be sent thru Cash App: $CoachR58.

Emergency Contact & Health Insurance Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Format: (000) 000-0000.

YesNo

Please describe*

Parental Permission For Emergency Treatment

In the event of illness or accident, I give my permission for emergency treatment by Coach Raphael or her staffl for my child, and I authorize Coach Raphael or her staff to take my child to:
I give consent for the facility to secure any and all necessary emergency medical care for my child.

Name of Physician / Emergency Medical Care Facility

Phone Number

Format: (000) 000-0000.

Release of Liability

Although the safety of all sport activities is the primary concern, indoor/outdoor sport activities at Coach Raphael, aka Deltona Krocz Basketball facilities may cause injuries and/or death to my child. I expressly assume the risk of injury, death, and/or illness arising from any cause, and agree to waive my right to pursue any lawsuit, claim against Coach Raphael, aka Deltona Krocz Basketball.

YesNo

Parent's Signature/ Child's Signature*