Bible Basketball Camp Registration Form

Child's Name Male Female Age Grade Going into School

Address City State Zip Code Daytime Phone # ^-^-

Emergency Phone # ^-^- Your Name Your relationship to Child (Must be parent or legal guardian)

Church Affiliation : How many years playing basketball?

Morning Session : (Ages 6-9) Boy Girl Afternoon Session : (Ages 10-13) Boy Girl

T-Shirt Size : Child 6-8 10-12 14-16 Adult Small Medium Large XL

Payment Enclosed (Check or Money Order): $15 Camp Fee $10 for Camp T-Shirt $25 Camp Fee (If registered after June 15^th, 2007) Total $

Note** (NO refunds will be given out after the 1st day of Camp)**

INSURANCE INFORMATION (Must be completed to be enrolled)

Insurance Company Policy Number

Family Physician Physician Phone ^-^- or ^-^-

Insurance company address Insurance company phone ^-^-

Authorization: I , the parent or guardian of , a minor, do hereby authorize Coffeyville Community College or Tyro Christian Church to select hospital facilities and/or physician of their choice and authorize treatment of the above named camper on an emergency basis in the event that such treatment becomes necessary as the result of participation in Bible Basketball Camp. I will be responsible for all medical bills incurred as the result of illness or accident in which medical treatment is necessary while the above applicant is at camp, except those bills covered by my family insurance. I release Bible Basketball Camp, Coffeyville Community College, Tyro Christian Church, and anyone acting on their behalf from any claims which might herein be presented by above named camper of such injuries. I also hereby grant permission to allow the above named camper to participate in all camp activities, except those specifically listed on this form, at the Bible Basketball Camp held at Coffeyville Community College.

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Signature Date