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Registration for 19th Annual Julius De Loatche Basketball Camp, summer 2018

[Right click this line, save file, open it in WORD,  fill it out, resave it, and attach to an email message to:

 james_deloache@yahoo.in] or Print and return completed form to:



Julius De Loatche Basketball Camp,Inc.
2310 West Moss Ave.
Peoria, IL 61604

For Information: Call 309-648-1428 or  309-673-8933

JULIUS  DE  LOATCHE SUMMER BASKETBALL CAMP REGISTRATION, 2018

ELGIBILITY: Grades 5-8 (Girls and Boys) Free !!!!

NAME_________________________________________________ AGE_____DOB _________

ADDRESS INCLUDING ZIP CODE_________________________________________________

HOME  PHONE ________________________________ CELL _________________

CHILD SHIRT SIZE: (CIRCLE)   SMALL     MEDIUM     LARGE      EXTRA LARGE

WAIVER RELEASE: I am a voluntary participant in this event and in good physical condition.  I hereby assume full and complete responsibility for any injury or accident which may occur during my participation in this event or while on the premises of this event, and I hereby release and hold harmless the Julius De Loatche Summer Basketball Camp, Inc. Julius De Loatche Summer Basketball Camp, Inc. may videotape and photograph this event for future publicity purposes.By attending or registering, the Camp reserves the right to use your image or likeness for future publication,website promotion or media release.

PARTICIPANT’S SIGNATURE___________________________________________________

PARENT’S/GUARDIAN’S SIGNATURE___________________________________________

PARENT/GUARDIAN PLEASE CIRCLE ONE OR MORE SELECTIONS BELOW:

I WILL HELP WITH: (A) COACHING  (B) DONATION  (C) FOOD OR BANQUET