WBB Summer Camp Sign-up Form

Email address *

First name *

Last name *

Address 1 *

City *

State *

ZIP Code *

Cell Phone Number *

Age *

Year in school *

What grade will you be in this coming fall?

4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade

High School *

Preferred Roommate(s)

Parent(s) Name(s) and Contact Information

Summer Camp Dates and Fees (The Rio Grande Women's Basketball Camp is $300 in total with a $100 deposit due with application). *

NOTE: Make Checks payable to: Rio WBB Camp Address: 218 North College Avenue Rio Grande, Ohio, 45674

Rio Grande Women's Basketball Camp - July 14-17 ($300)

What size t-shirt are you? *

Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult Xtra Large Adult Double Xtra Large

Assumption of Risk/Medical Consent

I wish to participate with the University of Rio Grande’s Women's Basketball Summer Camp on ______________.
The Women’s Basketball Program or anyone else connected with the University of Rio Grande will not be responsible for accidents or injuries that occur due to participation, nor will they be responsible for medical, dental, or any other expense incurred as a result of an accident or injury. I hereby assume voluntarily any risk of accident or injury to myself as a result of participation. I also grant the right to administer all medical services that may be necessary due to participation, including emergency or referral services.

Have you ever been told you have a heart condition? *

Yes / No, (If yes, please explain.)

Have you ever had a head injury / concussion? *

Yes / No, (If yes, please explain.)

Have you ever had a heat related injury/illness? *

Yes / No, (If yes, please explain.)

Are you currently taking any medications? *

Yes / No (If yes, please explain.)

Are you allergic to any medications? *

Yes / No (If yes, please explain.)

Do you have any Allergies? *

Yes / No, (If yes, please explain.)

Do you have Asthma *

Yes No

Do you have any medical conditions we need to be aware of? *

Yes / No (If yes, please explain.)

Emergency Authorization Information: Parent / Guardian *

Full Name / Cell phone number

Secondary Emergency Contact *

Full name / Cell phone number / Relation to camper

I hereby authorize the directors of the Rio Grande Women's Basketball Camp to act for me according to their best interest in case of emergency requiring medical with the basketball camp will not be responsible for medical, dental or any other expenses incurred as a results of an accident. *

Camper Signature / Date

I hereby authorize the directors of the Rio Grande Women's Basketball Camp to act for me according to their best interest in case of emergency requiring medical with the basketball camp will not be responsible for medical, dental or any other expenses incurred as a results of an accident. *

Guardian Signature / Date

* required field