Clone of Sign Up Deltona KROCZ Form

Deltona Krocz Basketball Camp

June 8th thru Aug. 3rd 2026

Boys & Girls: 8-16 yo.

Register $20

Camp fees: $50/weekly/pp

Cash App: $CoachR58

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 2:00 pm. Camp starts on June 8th thru Aug. 3rd. 2026.

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

· Sign Up fee is $20 per camper payable thru cash app or zelle.

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

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

I give Ann Raphael, permission to use any pics/videos as seem fit to include posting on social media...

Emergency Contact & Health Insurance Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Format: (000) 000-0000.

Does you have any allergies, chronic illness, or medical conditions that would limit high level activtiy?

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.

I have read and agree to the above conditions

Parent's Signature/ Child's Signature