Academy Skills & Drills Camp Registration Form

NOTE: A PHYSICAL EXAM SHOULD BE PERFORMED ON THE PARTICIPANT ANNUALLY.

Participant's Name

First Name

Last Name

Participant's Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Legal Guardian's Name

First Name

Last Name

Email

Phone

(###)

###

####

IN CASE OF EMERGENCY

Emergency Contact 1

First Name

Last Name

Contact 1 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact 1 - Phone

(###)

###

####

Emergency Contact 2

First Name

Last Name

Contact 2 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact 2 - Phone

(###)

###

####

MEDICAL INFORMATION

Participant's Allergies

Please list all known allergies including for food.

Participant's Medical Conditions

Please list all known medical conditions; NO MEDICATION CAN BE ADMINISTERED BY ACADEMY STAFF

Participant's Primary Physician

Physician's Phone Number

COST, LOCATION & WAIVER

Cost to participate in this camp is $25 per participant. PLEASE VENMO @EIQ_Academy, or pay with cash at the door. ADDRESS: 2316 Acme Rd., Belmont, NC 28012

How did you hear about us?

WAIVER OF LIABILITY AND RELEASE - I have authority to make decisions for the participant listed above. I am aware of the physical nature of basketball activities and I hereby assume responsibility for the above listed participant. I will not hold EIQ Basketball Academy and/or its employees responsible in the case of accident or injury as a result of this participation. By clicking "I agree" below, I agree to these terms.

I affirm and agree

I give EIQ Basketball Academy permission to photograph the participant listed above and use the likeness for news media and promotion.

I affirm and agree

Academy Skills & Drills Camp Registration Form

CONTACT

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