PARENT / GUARDIAN INFORMATION

PARTICIPANT / CHILD_____________________________________________________________

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FATHER/GUARDIAN ______________________________________________________________

MOTHER/GUARDIAN_____________________________________________________________

EMERGENCY COTACT____________________________________________________________

PHONE NUMBER _________________________________________________________________

PLEASE READ CAREFULLY AND SIGN BELOW TO INDICATE YOUR AGREEMENT. NOTE: THIS
FORM INCLUDES A RELEASE OF LIABILITY. Please review and complete the sections below and
sign in the space provided to indicate your agreement with all statements made in each section.
AUTORIZATION AND RELEASE OF LIABILITY: I, the parent or guardian of the above-named
child, authorize the participation of my child in the Scott Stewart Basketball Camps. I further
understand and agree that my child’s participation in athletic and other activities of the Program
involves the risk of injury. On behalf of my child, me, and my family, I assume these risks. In
consideration of the privilege of my child’s participation in the Camp, and on behalf of my child
and me as parent/guardian, I hereby release, discharge, hold harmless and agree not to sue,
Scott Stewart , First Baptist Church Naples, Marco Island YMCA, NNRPR, employees, and volun-
teers who are involved in the Scott Stewart Basketball Camps. I give permission for free use of
child’s name and picture in broadcasts, telecasts, or written accounts for any participation in a Scott
Stewart Basketball Camps.

MEDICAL CONDITIONS: I understand that participation in the Program may involve strenuous and
prolonged physical activity. I agree that my child is healthy and able to participate in the
Program activities. I understand that the camp or its representatives may request health infor-
mation concerning my child and/or ask my child to undergo a medical exam. If the program
directors determines that my child does have a physical or mental condition that may affect his/her
ability to safely and appropriately participate in Program activities, the Program directors may
determine that my child cannot be permitted to participate. I understand and agree that, while the
program directors desires that all children will be able to participate, such decisions may have to
be made out of concern or the best interest of my child and other participants.
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CONSENT TO MEDICAL TREATMENT: In the event my child is injured or becomes ill in Program
activities, and if I, the parent or guardian of the above-named child, am not present to make
medical decisions, I herby authorize the Church, YMCA,NNRPR, its staff, volunteers, including
volunteer parent participants, coaches, assistant coaches, and referees, and supervisors to arrange
June 3-5, 20th July13-17 20-24 27-31
for and consent on my behalf to emergency medical assistance. I am responsible for payment of
any medical charges or expenses not covered by my insurance or the insurance applicable to my
child (if any). My signature below indicates that all information provided in this form is true and
accurate, and that I fully agree to all statements made on the form, including but not limited to the
Authorization and Release of Liability, Medical Conditions, and Consent to Medical Treatment.
Each responsible parent/guardian should sign.

Signature(s): ________________________________________________Date: _______________

Printed Name(s):_________________________________________________________________

I affirm that this form was signed by only one parent/guardian because (1) I am the sole
parent/guardian responsible for the care and custody of the child due to death or incapacity of
3000 Orange Blossom Dr.

the other parent/guardian or court order, or (2) I have made a good faith effort to obtain the
signature from the other parent/guardian but have not been able to do so due to causes beyond
my control, and I am not aware of any reason that the other parent/guardian objects to the child’s
participation in the Program.
Naples, FL 34109
Scott Stewart

Signature: _______________________________________________ Date: __________________

Printed Name: ___________________________________________________________________

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 PROGRAM HIGHLIGHTS
Summer 2009
9:00 AM - 12:00 PM
• Fundamental Instruction
• Shooting
• Competitions
• Games & Fun
• Instructional Videos
• Guest Speakers
REGISTER NOW:
June Camps
June 3-5 camp cost is: $75.00
9am-12pm
June 20th Parent/Child Clinic:
cost is: $25.00
9am-1pm (lunch provided)
*instruction by Coach Don Stewart
MAKE CHECKS PAYABLE TO:
FBCN SportsOutreach
For more information contact
Scott Stewart at (239) 597-2233 x 659
sstewart@fbalions.org
July Camps
July 13-17—YMCA of Marco Island
12:30-3:30pm
MAKE CHECKS PAYABLE TO:
Marco Island YMCA
$100.00 per camper
$80.00 YMCA member
July 20-24– North Collier
Regional Parks & Recreation
July 27-31– North Collier Regional
Parks & Recreation
9am-12pm
$120.00 per camper
or $200.00 for 2 weeks
MAKE CHECKS PAYABLE TO:
NCRPR
PARTICIPANT CONTACT INFORMATION
Last Name ____________________________
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First Name ____________________________
Address_______________________________
______________________________________
City_____________________ State_________
Zip_____________
Phone (H)_______________________
(Cell)_____________________
Parent’s Email:
______________________________________
Player’s Allergies, Disabilities, Illnesses:
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______________________________________
______________________________________
Scott Stewart 2009
Summer Basketball
Camps
OPEN TO GRADES:
1st - 8th
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RETURN FORM TO:
Scott Stewart
1750 Reuven Circle #2
Naples, Fl 34112
597-2233 x 659