2022 Application Online Submission

Please complete the application below.

2022 Application

Name *

First

Last

Checkboxes *

Male
Female

Street Address, City, Zip *

Parent/Guardian Name (Mother - Occupation) *

Parent/Guardian Name (Father - Occupation) *

Parent Email Address *

Phone for Parent/Guardian *

Phone for Student *

Birthdate (MM/DD/YYYY) *

Medical Insurance Carrier

Doctor Name & Phone Number

Emergency Contact Name, Phone Number, Relationship to Camper

School Name & School District *

Grade Level *

T-Shirt Size *

I certify that the above statements are accurate and true to the best of my knowledge. In addition, I will follow the rules and regulations of the Ron Palmer Summer Basketball Camp/Hoop Smart at all times. If I am asked to leave the camp for behavior problems, I understand that monies are not refundable. I agree to be filmed and photographed and to use digital technology to participate in this camp. I understand that the Ron Palmer Summer Basketball Camp will strive to keep all personal information confidential. *

Applicant's Name (Print)

Applicant's Signature -- Date

Parent or Legal Guardian's Name (Print)

Parent or Legal Guardian's Signature -- Date

Message