PARENT AND MEDICAL
CONSENT/RELEASE FORM
My child has permission to attend the 2017 Rams
Basketball Camp. In the event of illness or injury,
I hereby grant permission for the attending
physician or appropriate medical personnel to
secure proper treatment. I will be responsible for
any other medical or other charges that may result
from my child’s attendance at the Cleveland Rams
Basketball Camp. In acceptance of this applicant
for camp, I hereby release Cleveland High School
and all its employees from all claims or damages
which may be sustained by my child in association
with this camp.
Staff
Cleveland Head Coach John Jacobs will lead
a knowledgeable staff of Basketball Coaches.
Cleveland Assistants, Jordan Boser and
Zack Miller, will assist Coach Jacobs.
Additions to the staff are expected as the
2017 Rams Basketball Camp nears. Present
members of Cleveland’s Basketball program
will be on hand to demonstrate drills and
aid with instruction.
2017
Cleveland High School
“Rams”
Basketball Camp
_________________________________________
Parent/Guardian Signature
_________________________________________
Date
_________________________________________
Emergency Phone Number
Is there a known history of:
(A) Medical conditions currently under treatment
(B) Preexisting injury currently under treatment
(C) Fractures or other disability type injuries
(D) Any medications being taken
(E) Allergies
(F) Mental disorder or physical handicaps
(G) Known past illness of more than 1 week
(H) Contact lenses or glasses
Explain any answers of “Yes” on a separate sheet
and include with application.
Questions/Concerns
Coach Jacobs will be available to address
any of your questions about camp on
Sunday, June 18th from 2:00-4:00 pm in the
main gymnasium at Cleveland High School.
Late registrations will be accepted on this
day. The daily schedule for camp will be
available for pick up at this time.
June 19-22, 2017
1:00 pm – 4:00 pm
Age Requirements
The 2017 Rams Basketball Camp is open
to both boys and girls from age 5 to 14.
Campers will be divided into three
groups based on age and/or ability. The
groups are (5-7), (8-10), (11-14).
Facilities
The Rams Basketball Camp will be held in
the main gym and auxiliary gym at
Cleveland High School.
Cost: 1 child—$80
2 children—$140
Application
Please submit the following:
Application, the Parent and Medical
Consent/Release Form and your payment
to:
RAMS Basketball Camp
C/o John Jacobs
1892 Polenta Road
Clayton, NC 27520
Name: _______________________ Age: _____
Mission
Address: ________________________________
Our goal as a staff is to make sure each
camper has a positive experience while
learning more about the game of
basketball. We will do this by teaching
the fundamentals of the game through
instruction, drills, and game situations.
City: ________________ State: ____Zip: _____
Parent/Guardian(s) names:
________________________________________
Home Phone: ___________________________
Work Phone: ____________________________
T-Shirt Size _________ (Youth S, M, L)
(Adult S, M, L, XL, XXL)
What to bring
Participants should wear comfortable
clothing and tennis shoes.
INSURANCE INFORMATION:
Company: ______________________________
Policy Holder: ___________________________
Camp Perks
Awards will be given for each age group
based on offensive ability, defensive skill,
hustle, and best all-around. Each camper
will receive a camp T-shirt.
Policy Number: _________________________
** Make checks payable to:
Cleveland Rams Booster Club