Collegiate Prep Basketball Academy Form

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Davis Academy Grades 2-4

Last Name:
First Name:
Birthday:	Age:
Address:
City:
State:	Zip:
Phone Number:
School:
Grade:
Parent's Name:
Parent's Email:
Alternate Email:
Alternate Email 2:
Cell Phone:	Cell Phone 2:
Insurance Company:
Insurance Policy Number:
Medical Concerns (if any):
Emergency Contact Name:
Phone:
Relationship:

Choose the session to attend:
Boys Grades 2-4
Girls Grades 2-4

I give my son/daughter permission to participate in the Davis Academy Basketball Program.

I hereby grant permission to Collegiate Prep Basketball Academy to have my child treated by a physician if necessary and waive any and all liability or any costs associated from any injuries that may occur involved with the participation of camp.

I agree to allow Collegiate Prep Basketball Academy to use my child’s photograph and likeness on any website, brochures, or other promotional materials.

By submitting this form, I agree to the waiver and liability clauses. This has legal standing as if it where your signature.

I agree to the above statements

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