Glenn Patterson Jr.

1st Annual Basketball Skills Camp

June 12- 14, 2017

REGISTRATION FORM

PARTICIPANT INFORMATION Please type or print legibly.

Last Name: First Name: ___________

Gender: Female Male Age: _ T-Shirt Size____________

School:

Grade attended year 2017-2018 :_____________________

Home address:
City: State/Province: Postal/Zip Code:
Country: Telephone: Cell:
Parent email:
(Include area code with telephone)
Please list ADA Accommodations needed:

Parent(s) Name: _______________________________________________________________

Parent(s) Phone Number:________________________________________________________

Persons Authorized to pick up child:________________________________________________

Other Dismissal Arrangements_________________________

Emergency contact*: Relationship: Phone:

Specify any of your childs health problems:

Is your child on any medication? No Yes If so, please specify:

Payments: Camp Tuition may be paid by cash or by check.

Make the check payable to: Glenn Patterson Jr.

Camp Fees:
$55.00/Per Camper Before June 4th
$65.00/Per Camper June 5th Until first day of Camp 06/12/2017

Contact Information
For more information, contact Glenn Patterson Jr., Camp Director at
910-853-8646 or Glenn Patterson Sr., Camp Assistant Director at 910-740-8784
Emails: glennpatterson910@gmail.com
SIGNATURE OF PARENT OR GUARDIAN __ DATE

DROP OFF AND PICK UP TIMES

Drop off time:
Ages 6-11
8:30AM
Ages 12-18
12:30PM

Pick up time:
Ages 6-11
12 PM
Ages 12-18
4PM

REQUIRES PARENTS SIGNATURE:

You have our permission, in the event of an emergency and in case we are unavailable, to authorize any
physician, nurse practitioner or medical personnel to examine, interview, test and if necessary, treat my
child_______________________________________________ as they may deem advisable.

Parent/Legal guardian name________________________________________________Date_______________

Parent/Legal guardian Signature_____________________________________________Date_______________

Student Allergies________________________________________________________________

Student Medical Problems_______________________________________________________________

I hereby give permission to Glenn Patterson Jr. , to photograph and/or videotape the student for
educational or promotional purposes. ________ (Initial)

PARENT STATEMENT

I hereby state that (campers name) ___________________________________________ is in good mental

and physical health condition to participate in the activities provided by Glenn Patterson Jr.

Parent Signature_____________________________________________Date___________