St. Michael the Archangel High School
Lady Warriors’ Back to School Basketball Camp
Starts: 19 August 2013 Ends: 23 August 2013
Time: 5:00 – 7:30 pm
COST: $ 60 per player
Open to: Girls age 12-18 (middle school & high school players)
RSVP by August 15th
REGISTRATION FORM
Camper’s Name ______________________ Age
_______________________________________
Parent’s Name _______________________ Phone
#___________________________________
Address ______________________________ Cell#
_______________________________________
City/State/Zip
___________________________________________________________________
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Email
___________________________________________________________________
_____________
Emergency Contact and Phone#
______________________________________________
Parent /Guardian signature
____________________________________________________
Please submit this form to:
SMHS Basketball Camp
6301 Campus Dr.
Fredericksburg, VA 22407
Make checks payable to SMHS
Athletic Camp /Clinic Sports Medicine Information sheet
Please provide the following information for your child:
Primary emergency contact:
Name ___________________________________________
Relationship______________________________________
Phone number ____________________________________
Secondary emergency contact:
Name ___________________________________________
Relationship______________________________________
Phone number ____________________________________
Allergies (medication, food, bee sting, poison ivy, etc)
Please describe the nature of the reaction (rash, hives, difficulty breading, etc
________________________________________________
________________________________________________
Injury history (eg, recent sprains, fractures)
________________________________________________
________________________________________________
Medical conditions (eg. Asthma, diabetes, cardiac disorders, seizure disorders)
________________________________________________
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Medications currently taking:
________________________________________________
________________________________________________
Date of last tetanus shot (month/ year)
________________________________________________