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 ___________________________________________________________________ ___ 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) ________________________________________________ ________________________________________________ Medications currently taking: ________________________________________________ ________________________________________________ Date of last tetanus shot (month/ year) ________________________________________________