Camper's Name________________________________________Date of Birth_________________

Address_______________________________________________City / State / Zip_____________

Home Phone__________________________E-Mail______________________________________

Parent's Work Phone___________________________________Emergency Phone______________

Parents Name(s)__________________________________________________________________

School_________________________Coach__________________________Phone_____________

AAU / Select / Youth League Team / Coach_____________________________/________________

Session:        Post_________Shooting________Skills__________     Day:__________  Time:_______

Please make checks payable to:    The Basketball Place

                                                C/O  13311 Poplar Tree Rd.

                                                      Fairfax, VA 22033

Medical Consent

I hereby state that my child is in good normal health and has my permission to participate in all camp activities.

In addition, I authorize the camp staff to act in the event of injury or sickness.  A registration requires that a

parent/guardian sign below to agree that in case of an accident involving their child while participating in the camp

program at The Basketball Place, Inc.  they release the corporation, the director, and all officers of the

corporation and instructors of the camp programs from any and all liability.

Date_______________Signed____________________________________________________________

Print Name of Person Signing______________________________________________________________