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Registration for 20th Annual Julius De Loatche Basketball Camp, summer 2019

Registration Form [fill out and email to [james_deloache@yahoo.in] or Print and return completed form



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, 2019

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

NAME_________________________________________________ AGE_____DOB _________

ADDRESS INCLUDING ZIP CODE_________________________________________________

HOME  PHONE ________________________________ CELL _________________

EMERGENCY CONTACT _________________________________CELL/PHONE_________________________

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 that 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/or photograph this event for future publicity purposes.

If you register and/or attend, the Camp reserves the right to use your image or likeness in future publications, promotions, or media appearances.

PARTICIPANT’S SIGNATURE___________________________________________________

PARENT’S/GUARDIAN’S SIGNATURE___________________________________________

I hearby give permission for medical treatment, including but not limited to transport to and for emergency care, to the Julius De Loatche Summer Basketball Camp, Inc. and medical transport and/or service providers. I hearby accept financial responsibility for said medical transport/treatment.

PARENT’S/GUARDIAN’S SIGNATURE___________________________________________

Insurance provider: ________________________________policy number: ______________________________

Covered parent/guardian: _________________________________________________

Please list participant's medical conditions and/or allergies to medicines/treatments:

_______________________________ __________________________________ ________________________

PARENT/GUARDIAN PLEASE CIRCLE ONE OR MORE SELECTIONS BELOW:

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