RICHMOND HEIGHTS LOCAL SCHOOLS
2016 SUMMER ~ BASKETBALL CAMP
REGISTRATION FORM
SECONDARY SCHOOL
June 27 – July 22
4 weeks
1:00 pm – 3:00 pm
Student’s Name (Print):
(First)
(Middle)
(Last)
(First)
(Middle)
(Last)
Parent’s Name (Print):
Address:
City:
Phone Number:
Zip:
Cell Phone Number:
Email:
Date of Birth:
Grade in the 2016/2017 (next year) school year:
MIDDLE SCHOOL CAMP:
 6th Grade
 7th Grade
 8th Grade
HIGH SCHOOL CAMP:
 9th Grade
 12th Grade
 10th Grade
 11th Grade
Fees: (Payable to: Richmond Heights Board of Education)
$15.00 for Richmond Heights Local School District Students
$25.00 for Non- Richmond Heights Local School District Students
RELEASE OF LIABILITY/MEDICAL TREATMENT CONSENT
I hereby release and hold harmless and agree to indemnify the Richmond Heights Local School District
(RHLSD) and its employees, agents, and representatives from any and all claims, cost, damages, and liabilities
for injuries or property damage sustained or caused by me or my child or ward while participating in any
program offered by the RHLSD. I understand that fees do not include accident or personal property insurance.
I further represent that I am, or my child or ward is, physically capable of participation in the program based
upon consultation with my, or my child’s or ward’s personal physician.
Further, in the event of any injury, I hereby give my permission and consent and authorize emergency first aid
and/or hospital care of treatment for my child/ward if deemed necessary by qualified medical or emergency
personnel or by said employees, officers, agents, or representatives of the RHLSD, and further agree to assume
all expenses for said treatment.
Signature of Participation or Minor’s Parent/Legal Guardian:
Date:
RICHMOND HEIGHTS LOCAL SCHOOLS
2016 SUMMER ~ BASKETBALL CAMP
CONSENT FOR EMERGENCY MEDICAL TREATMENT
I,
, as the parent or legal guardian of
Name of Parent/Legal Guardian
, hereby give my permission for any
Name of Child
and all emergency treatment deemed necessary by medical or city personnel for the above-referenced minor,
, as a result of any injuries occurring
Name of Child
during participation in Secondary Summer Basketball Camp
and I agree to be financially responsible
Name of Camp
for any such treatment.
I also consent that the reports of any treatment so rendered be forwarded to the primary care physician,
whose name and address are listed below.
This consent shall endure from
6/27/2016
Date
until
7/22/2016
.
Date
Signature of Parent or Legal Guardian
Date
PLEASE FILL IN THIS BRIEF HISTORY ON YOUR SON OR DAUGHTER TO AID ANY
PHYSICIAN WHO MIGHT TREAT HIM/HER.
PARENT/LEGAL GUARDIAN’S NAME:
ADDRESS:
CITY/STATE/ZIP:
PHONE NUMBER (H):
CHILD’S PHYSICIAN’S NAME:
ADDRESS:
AFFILIATED HOSPITAL (IF ANY):
ALLERGIES:
CHRONIC ILLNESSES:
INSURANCE COMPANY:
PHONE (C)(W):
PHONE:
RICHMOND HEIGHTS LOCAL SCHOOLS
2016 SUMMER ~ BASKETBALL CAMP
SECONDARY SCHOOL
June 27 – July 22
4 weeks
1:00 pm – 3:00 pm
Camp Director is Spartan Coach Carlon Brown
Strengthening the Spartan Basketball tradition while connecting with our community at-large
 Registration begins May 6, 2016 and ends May 27, 2016
 Middle school camp is open to students entering grade 6 through students entering grade 8
 High school camp is open to students entering grade 9 through students entering grade 12
 Held in the middle and high school gyms simultaneously
 Runs from June 27-July 22
 The two weeks of June 27th and July 5th will be developmental skills camp
 The two weeks of July 11th and July 18th will be league play amongst the campers
 Teams will be player/coached by Richmond Heights basketball players, all under the
direction of Richmond Heights coach Carlon Brown
 The cost is $15 for RHLSD students
 The cost is $25 for non-RHLSD student
 Campers will receive a t-shirt and backpack
Transportation will NOT be provided for campers