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Name:__________________________ Parent's Name:___________________ E-mail: _________________________ Address:________________________ City:___________________________ State/Zip:_______________________ Home Phone:(_____)______________ School/City:_____________________ Grade: (08-09)___________________ Circle One Please: Camp 1 (4th-6th) Camp 2 (7th-9th) Age:___________________________ T-shirt size CM CL S M L XL Number on Shirt:________________ Please fill out the permission to treat form to the right and send this page with $50 (please make checks payable to NEWLHS Basketball Camp) to: BOYS BASKETBALL CAMP Questions? Please Call: Mark
Meerstein I look forward to seeing you at camp. God bless, Coach Meerstein |
Permission to Treat Form I authorize camp and/or school personnel to transport my son to a physician's office and/or emergency room for treatment in the event that emergency medical care is needed while he is involved in the NEWLHS Basketball camp. Further I authorize the PHYSICIAN and HOSPITAL STAFF to treat my son, as they deem necessary in the emergency situation. Parent/Guardian Signature: __________________________________ Date: _____________________________ Insurance Carrier: __________________________________ Policy #:___________________________ Known Allergies:_________________________ Medical Conditions and/or Medications _______________________________________ Father's Full Name: ________________________ Father's emergency phone:__________________ Mother's Full Name:_______________________ Mother's emergency phone:_________________ Family Doctor's phone:_____________________ Family Dentist's phone:_____________________
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