Pathways to Success Programs explore Basketball
2015 SUMMER EXTREME BASKETBALL CAMP
APPLICATION FORM
SUMMER EXTREME BASKETBALL CAMP
The Extreme Action Basketball Camp is an exclusively intense Conditioned Theory camp
where young people find their true threshold mentally and physically on the basketball court
while passing average set limits of basic fundamental training. Throughout the week, studentathletes of all skill levels learn how to achieve peak performance on the court while
developing stronger focus skills, enhanced team building and understanding how to combine
the right attitude on the court, in the classroom and with life decisions. The camp is hosted by
former UCLA, NBA, Europe basketball player, Rodney Zimmerman who is currently a
national motivator for youth around the country.
Dates: July 20th - July 24th
Time: 9 a.m.- 4 p.m.
Location: Windsor Forest High School
 Basketball Technique;
 Develop problem-solving, organizational, and;
 Team-building skills
Eligibility: 100 participants, grade levels 9th -12th, a letter of recommendation from
teacher, or guidance counselor or supervisor in addition to the application form
along with the $50 registration fee (money order ONLY) to: Pathways to Success
Programs/ Extreme Basketball Camp
PARTICIPANT INFORMATION:
Name:
___
__
Age: ____
Sex:
□ Male □ Female
T-Shirt Size: □ Child /□ Adult: □ Small □ Medium □ Large
School _____________________________________________________________
GPA_____________
Email[s]: _____________________________________ / _______________________________________
Cell phone[s]:
(______ ) _________________________
(______ ) ____________________________
I hereby apply to be a member of the SAVANNAH 100’s YOUTH and I understand and agree to
abide by its requirements. I promise to be kind and respectful to my fellow students and all others.
Participant Signature: ________________________ Date: ______________________________
PARENT OR GUARDIAN INFORMATION:
Name:
___
__
Date:
___
Address:
City:
_________
______
Phone:
State:
Zip:
Alternate Phone:
Email:
___
___
___
Consent, Release and Waiver Form
I, ________________________, the parent and/or guardian of _______________________
(“Mentee”), hereby give my consent for him/her to participate in the 100 Black Men of
Savannah, Inc. (“Savannah 100”) youth mentoring programs. I also agree that:
1. Program staff, volunteers, Collegiate 100, and members of the Savannah 100, have
my permission to provide Mentee reasonable first aid and transportation to a health
care facility in the event Mentee needs emergency medical attention. I agree to
release any records necessary for treatment, billing, referral or insurance purposes in
the event Mentee is transported to a health care facility for emergency medical
attention.
2. Pictures and video or audio recordings of Mentee participating in the Program are
hereby released by me for use in appropriate news media (e.g. newspapers, radio,
and television stations) and in the marketing materials for the Savannah 100 (e.g.
website and brochure).
3. In consideration of Mentee being allowed to participate in the program I agree on
behalf of myself, Mentee, any other parent or guardian of Mentee, and any personal
representative, agent, heir, successor or assign of the foregoing (hereinafter
“Mentee’s parties”) to forever and irrevocably indemnify, hold harmless, waive
liability, release and discharge Savannah 100, 100 Black Men of America, Inc.,
Program staff, and any corporate entities, officers, directors, members and
employees related to any of the Program from any and all claims, demands, causes of
action, rights, costs and charges of whatever kind or nature, arising out of or related
to any known or unknown, foreseen or unforeseen bodily or personal injury, death,
or property damage, resulting from Mentee’s voluntary participation in Program.
4. In consideration of Mentee being allowed to participate in the Program, I covenant
and agree on behalf of Mentee’s parties that Mentee’s parties will not sue Program
parties for any claims for damages arising from or related to Mentee’s voluntary
participation in Program.
5. Assumption of Risks: Engagement in Athletic Activities carries with it certain inherent
risks that cannot be eliminated regardless of the care taken to avoid injuries and that
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participation in any physical activity involves peculiar risks that even when safety
precautions are utilized, injuries can occur. I also understand that if I experience pain
or physical discomfort during these activities I will decrease or stop participating. I am
aware that personal health/accident insurance is my sole responsibility. I affirm that
to the best of my knowledge, I do not have any medical condition or physical
disability that will preclude my safe participation.
6. I have read the previous paragraphs and I know, understand, and appreciate these
and other risks that are inherent in The Engagement of Athletic Activities and
participation in attendant activities. I hereby assert that I knowingly assume all such
risks.
I hereby acknowledge that I have read this form and agree to waive certain legal rights by
signing this Consent, Release and Waiver.
BY:
PARENT/GUARDIAN
Date: ____________________
SCHOLARSHIP SECTION
HOUSEHOLD INFORMATION
Household Size: □-1
□ -2
□-3
□-4 □-5
□-6
□-7
□-8
□-Other
______________
[please specify]
Total Household Annual Income $ ____________________________
Proof of Income: ________________________________________ (W4s; Pay-Stubs; Award Letters;
etc.)
Who
is
financially
responsible
for
the
child’s
tuition?
________________________________________________________________________________
In order to qualify for a private scholarship for the $50.00 participation fee, you must have an
annual household income (before taxes) that is at or below the following amounts:
HOUSEHOLD SIZE*
MAXIMUM INCOME LEVEL
(PER YEAR)
1
2
3
4
5
6
7
8
$15,171
$20,449
$25,727
$31,005
$36,283
$41,561
$46,839
$52,117
YOUR FAMILY
(CHECK ONE)
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*For households with more than eight people, add $5,278 per additional person.
Please complete the application and mail to the address listed below before May, 29, 2015.
Pathways to Success Programs/ Extreme Basketball
ATTN: Mrs. Q. Joyner
P.O. Box 14606
Savannah, GA 31416
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