Heal the Hood Foundation of Memphis Live the Dream Basketball Camp REGISTRATION FORM $5.00 Fee Friday, June 20, 2014 Time: 9:00am – 2:00pm Ridgeway High School 2009 Ridgeway Memphis, TN 38119 Heal the Hood Foundation of Memphis have launched events and programs that will aid in increasing the peace and overall health in our communities that brings together families throughout the city of Memphis in a fun-filled event with prizes, music and celebrities that care about the social and emotional health of their fans. This year summer event will launch with the Living the Dream Basketball Camp for children ages 8 – 16. Camper Information Name: _______________________________________________ Age: ______________ Gender: ____M ____F Date of Birth: ________________________________________ Address: ________________________________________________________________ City: _______________ State: ___________________ Zip: ______________________ Phone with area code: _____________________________________________________ Email: __________________________________________________________________ How did you find out about this camp? ________________________________________ Parent/Guardian Information Parent/Guardian’s Name: ___________________________________________________ Relationship to Child: _____________________________________________________ Home Phone: _______________________ Cell Phone: ___________________________ Address: ________________________________________________________________ Email: __________________________________________________________________ Employer Name: _______________________ Work Phone: _______________________ Please list any special medical conditions, medications, or other relevant info about the camper. _________________________________________________________________ ________________________________________________________________________ Family Physician (Name, address & phone): ___________________________________ ________________________________________________________________________ Emergency Contact # 1: ____________________________________________________ Relationship to Child: __________________ Phone: ( ) ________________________ Emergency Contact #2: ____________________________________________________ Relationship to Child: __________________ Phone: ( ) ________________________ Heal the Hood Foundation of Memphis Live the Dream Basketball Camp Registration Agreement I understand that there is a $5.00 fee and is for children between the ages of 8– 16. The camp is Friday, June 20th from 9:00am - 2:00pm and is limited to a maximum of 400 kids (therefore, selected campers will be granted on a first come first served basis). I agree to pick my child (ren) up by 2:00pm on Friday or have authorized persons to pick him/her up by that time. I understand that if I or the authorized person (s) does not provide adequate transportation to and from the site that it is not the responsibility of the HTH CEO, staff, participants or the camp hosts to provide transportation or monies for transportation. I understand that my child must arrive promptly at Ridgeway High School gymnasium located at 2009 Ridgeway, Memphis, TN 38119. I agree that my child (ren) will be under the rules of the Ridgeway coach and/or principal, the HTH staff, participants and/or camp directors reserve the right to disqualify the participation of my child (ren) for any violation of expectations and rules of the camp. I understand that I will be expected to remove my child (ren) from the premises safely and expeditiously if such an incident occurs. I authorize the camp directors/hosts or HTH participants/staff to arrange medical care for the above named camper. I understand that HTH will not be held liable for any stolen property, accidents, or providing any form of medical treatment or procedures during or after the summer basketball camp. Please make sure that your child (ren) has appropriate medical coverage. HTH will not be responsible for any medical expenses that may occur during your child (ren)’s stay. By signing this agreement you confirm and acknowledge your (parent/guardian) responsibility and obligation for any and all property damages. By enrolling in camp, the parent(s) certifies that the child is amenable to discipline and is free from habits that would make him/her an undesirable camper, and you release the Heal The Hood Foundation of Memphis (HTH), Shelby County Schools, its agents, participants, and volunteers from any claims for accident, injury or loss of valuables that may occur during the camper's stay at Ridgeway High School. You acknowledge release and waiver of any claim for damages from any such accident, injury or loss. Child’s Name (Please Print) ______________________________________________________________________________ Parent Signature (s) Date ______________________________________________________________________________________ Parent Name (s) (Please Print) Contact Phone # 1 Contact Phone #2 PLEASE RETURN PAGE TO A HTH REPRESENTATIVE Natasha Hill nhill@hthmemphis.org Heal the Hood Foundation of Memphis Live the Dream Basketball Camp All-Star Celebrity Basketball Game Saturday, June 21, 2014 3:00pm Registration Agreement Camper’s Copy Heal the Hood Foundation of Memphis have launched events and programs that will aid in increasing the peace and overall health in our communities that brings together families throughout the city of Memphis in a fun-filled event with prizes, music and celebrities that care about the social and emotional health of their fans. This year summer event will launch with the Living the Dream Basketball Camp for children ages 8 – 16. I understand that there is a $5.00 fee and is for children between the ages of 8– 16. The camp is Friday, June 20th from 9:00am - 2:00pm and is limited to a maximum of 400 kids (therefore, selected campers will be granted on a first come first served basis). I agree to pick my child (ren) up by 2:00pm on Friday or have authorized persons to pick him/her up by that time. I understand that if I or the authorized person (s) does not provide adequate transportation to and from the site that it is not the responsibility of the HTH CEO, staff, participants or the camp hosts to provide transportation or monies for transportation. I understand that my child must arrive promptly at Ridgeway High School gymnasium located at 2009 Ridgeway, Memphis, TN 38119. I agree that my child (ren) will be under the rules of the Ridgeway coach and/or principal, the HTH staff, participants and/or camp directors reserve the right to disqualify the participation of my child (ren) for any violation of expectations and rules of the camp. I understand that I will be expected to remove my child (ren) from the premises safely and expeditiously if such an incident occurs. I authorize the camp directors/hosts or HTH participants/staff to arrange medical care for the above named camper. I understand that HTH will not be held liable for any stolen property, accidents, or providing any form of medical treatment or procedures during or after the summer basketball camp. Please make sure that your child (ren) has appropriate medical coverage. HTH will not be responsible for any medical expenses that may occur during your child (ren)’s stay. By signing this agreement you confirm and acknowledge your (parent/guardian) responsibility and obligation for any and all property damages. By enrolling in camp, the parent(s) certifies that the child is amenable to discipline and is free from habits that would make him/her an undesirable camper, and you release the Heal The Hood Foundation of Memphis (HTH), Shelby County Schools, its agents, participants, and volunteers from any claims for accident, injury or loss of valuables that may occur during the camper's stay at Ridgeway High School. You acknowledge release and waiver of any claim for damages from any such accident, injury or loss. (PLEASE KEEP THIS PAGE FOR YOUR RECORDS)