2015 Basketball Camp Registration Form and Information
A community partner program by: 2015 MIAMI COUNTY Community Basketball & Volleyball Camps at TigArena Sponsored by: GIRLS Combined Basketball & Volleyball Camp BOYS Basketball Camp Monday, June 15 – Friday, June 19 Grades 1-4* 1-2pm Grades 5-8* 2:30-4pm *Based on grade entering in the fall Monday, June 15 – Friday, June 19 Grades 1-4* BB: 9:30-10:45am; VB: 11am-12:15pm Grades 5-8* VB: 9:30-10:45am; BB: 11am-12:15pm *Based on grade entering in the fall Location: Peru High School TigArena Location: Peru High School TigArena & Tiger Den Contact: Head Coach Jim Metcalfe 765-475-6834 jmetcalfe@peru.k12.in.us Basketball: Head Coach David Weeks: 472-4271 dweeks@peru.k12.in.us Volleyball: Coach Katie Wyant: 244-0538; kwyant@peru.k12.in.us REGISTRATION FORM Registration can be completed at any Peru School (Athletic or Admin Office; checks payable to Peru Basketball) or the Miami County YMCA (checks payable to YMCA). Fee: $25/participant, includes T-shirt & all activities. Pre-registration is encouraged to ensure T-shirts are delivered in quantity and on time; walk-in registrations on the first camp day will also be accepted. Financial assistance is available through the YMCA. CHECK ONE: __ Boys Basketball __ Girls Basketball & Volleyball* *no additional fee for combined camp __ Girls Basketball Only __ Girls Volleyball Only Name:__________________________ Telephone:_________________ Address:_______________________________ Age:________ T-Shirt size (Circle): Youth: Small Medium Gender: M Large F Adult: Small 2015-16 Grade:__________ Medium Large XL Parent/Guardian Names:____________________________________________________ Name(s) of Emergency Contact:______________________________________________ Emergency Phone Number:_____________________ Relationship:_________________ WAIVER OF LIABILITY AND DISCLAIMER To induce the Miami County YMCA (YMCA) and Peru Community Schools (PCS) to accept registration and permit participation in the program by the named individual, I hereby agree to release, indemnify, and hold harmless the YMCA and PCS, its officials, coaches, and representatives from any claim arising out of injury to the named individual. We also hold harmless the YMCA and PCS, its officials, coaches, and representatives, from any claim arising out of injuries or conditions caused by or aggravated by our/my refusal to obtain available medical treatment based on religious or philosophical beliefs. I hereby certify that the named individual is in normal health and capable of safe participation in this program. I assume all risks and hazards incidental to the conduct of this program and for the transportation to and from the program. I hereby authorize the YMCA and PCS to obtain medical treatment for the named individual in the event that the emergency contact (or parent if applicable) cannot be reached. Parent or Guardian Signature: ___________________________________ Date: ____________________ SPORTS STRENGTHEN CHARACTER Miami County YMCA 34 E. 6th St. Peru, IN 46970 Community Basketball & Volleyball Camps For Grades 1-8 June 15-19 Basketball Camps for Boys entering Grades 1-8 Basketball & Volleyball Camps for Girls entering Grades 1-8 Boys: June 15-19 Girls: June 15-19 Led by Peru HS Varsity coaches at TigArena & Tiger Den $25/participant Complete enclosed form and return to the Y or any Peru School office by June 12. MIAMI COUNTY YMCA More info: 765-472-1979 mdemchak@mcymca.org
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