Name: _______________________________ Grade Level (Fall 2012): ________

Phone: ____________________________   Physical (yes/no) _______________

Emer. Phone: ______________________  Camper's Age: __________________

School: ___________________________  Years at Brookville Camp: _________

Parent/Guardian Name:_______________________________________________

Address:___________________________________________________________

City:___________________________________________  State:_____________

Zip:________________________

E-Mail Address:_____________________________________________________

Family Medical Insurance Company:_____________________________________

Circle One:
Deposit-$25  -  Full Payment (before June 1)-$85   Late register (after June 1)-$95

I understand that participation in the Brookville Basketball camp involves risks and the possibility of serious injury. I herby release, hold harmless, discharge and agree not to sue or hold responsible Brookville Basketball, Brookville High School, directors, coaches, players or volunteers for all liability from my child's participation in this camp or any activities associated with the camp.

Parent/Guardian Signature:____________________________________________