CORNELL COLLEGE SUMMER CAMP
ACKNOWLEDGMENT AND ASSUMPTION OF RISK AND
MEDICAL CONSENT FORM
Cornell College
Basketball Camps
2014
I, the undersigned camp athlete, do hereby expressly and affirmatively state that I voluntarily wish to praticipate in the Cornell College
Basketball Camp.
I realize that my participation in this activity inherently involves risk
of injury, including but not limited to the following: death, neck and
spinal injuries (whick may result in complete or partial paralysis), brain
damage, injury to internal organs, injury to the skeletal system, and
injury or impairment to the body’s general health and well-being. In
addition, I acknowledge that injury may also result in serious impairment of future abilities to earn a living, engage in other business,
social and recreational activities, and generally enjoy life. These types
of injuries may result from my own actions, the actions or inactions of
others or a combination of both.
I understand that the rules and regulations are designed for the
safety and protection of the participants and I hereby agree to abide
by the rules and regulations administered by the camp staff. I also
understand that certain activities require a minimum level of fitness
for safe participation.
I acknowledge that I fully understand the contents of this Acknowledgment and Assumption of Risk statement before signing the same
and have had an opportunity to ask questions. All questions I have
asked have been answered to my complete satisfaction. Having done
so, I agree to assume any and all potential risks of these activities
and agree to hold Cornell College, its officers, employees, and agents
harmless for liabilities as it relates to this activity.
I hereby grant permission to the Cornell College camp staff, team
physician, athletic trainers, and other medical personnel to render aid,
emergency treatment, medical or surgical care, preventative, rehabilitative care deemed reasonably necessary to my health and well being.
Camp Athlete Signature
Friday April 11
Girls/Boys Three-On-Three Tournament
June 23-27
Girls/Boys Day Camp
July 24-27
Date
Parent(s) or Legal Guardian Signature
Date
CONTACT INFORMATION IN CASE OF
EMERGENCY:
NAME __________________________________________
ADDRESS _______________________________________
CITY ___________________STATE ____ZIP ___________
E-MAIL __________________________________________
HOME PHONE ___________________________________
CELL#__________________WORK#__________________
GRADE (Fall ‘14)__________
Brent Brase
Cornell College
600 First Street SW
Mount Vernon, IA 52314
Girls/Boys Elite Academy
By Arrangement
Individual/Group Lessons
www.cornellcollege.edu/athletics/
camps-clinics/index.shtml
GIRLS/BOYS THREE-ON-THREE TOURNAMENT
GIRLS/BOYS DAY CAMP
Friday April 11
June 23-27
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• Morning session for grades K-5, 9 a.m.-noon
• Afternoon session for grades 4-9, 1-4 p.m.
• Friday session will include a parent program for each
session
• Cost: $80.00
• Director: Brent Brase, Cornell Women’s Basketball
The girls’ and boys’ middle school camp stresses
fundamentals while incorporating team concepts and play
Emphasis will be placed on developing individual
offensive and defensive skills. Teaching sessions will
include instruction on shooting, dribbling, passing,
rebounding, team defense, team offense, individual
defense, and individual offense.
The girls’ and boys’ elementary camp is designed to
introduce and teach the basic fundamentals of basketball.
The camp utilizes a variety of innovative teaching
methods, drills, and games to teach these fundamentals
while not losing sight of the primary purpose of camp:
TO HAVE A GREAT EXPERIENCE!
Each camper will receive a Cornell basketball shirt.
Divisions: 2nd/3rd grade, 4th/5th grade, 6th/7th grade
5 p.m. start time
Registration deadline: April 9
Cost: $40.00/team
Gender: boys and girls
T-shirts for all first place teams
Three games guaranteed
Games are played to 20 points or 20 minutes
Maximum five player roster
Grades will be split if enough teams in each grade
Rules will be sent to the team captain
For camp information contact:
Brent Brase, Women’s Basketball Coach
[email protected]
319-895-4265
GIRLS/BOYS ELITE ACADEMY
PRIVATE INDIVIDUAL/GROUP INSTRUCTION
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Lesson taught by Coach Brase
Sessions may include from 1-5 players
Sessions to be arranged on an individual basis
Each session is $40 for an individual or $10 per
additional player
Lessons provided from April-August
Contact: Brent Brase, Women’s Basketball Coach
[email protected] (319)-895-4265
July 24-27
• Grades 4-8
• Cost: $180/Commuter or $230/Resident
• Check-in: Thursday, 5-6 p.m.
• Daily Sessions: 9-11:30 a.m., 1-5 p.m., 6:30-9 p.m.
• Check-out: Sunday, 11 a.m.
• Air Conditioned Dorms
• Includes Point Guard, Shooting Guard, and Post
The goal of the camp is to refine fundamental basketball
techniques, while also introducing and developing
advanced skills, and concepts necessary to take your game
to the next level. The high intensity level, combined with
low player to coach ratios, will maximize your skill
development and confidence.
• Commuters: lunch and dinner included in cost
• Resident: all meals and housing included in cost
REGISTRATION
Name__________________________________
Address________________________________
City_______________State_____Zip________
Home Phone____________________________
Cell Phone______________________________
Email_________________________Grade____
T-shirt size __YS__YM__YL__AS__AM__AL
CAMP(S) ATTENDING
Girls/Boys Three-On-Three Tournament: April 11
Team Name_________________________________
Divisions:___2nd/3rd ___4th/5th ___6th/7th
Gender: ___Boys ___Girls
Registration deadline: April 8
Cost: $40.00/team
Captain Contact info: Name______________________
Address______________________________________
City___________________State_____Zip__________
Email_______________________________________
1) Player name______________________grade_____
Parent Signature______________________________
2) Player name______________________grade_____
Parent Signature______________________________
3) Player name______________________grade_____
Parent Signature______________________________
4) Player name______________________grade_____
Parent Signature______________________________
5) Player name______________________grade_____
Parent Signature______________________________
Girls/Boys Day Camp: June 23-27
_____Commuter a.m. (9 a.m.-noon, Grades K-5) $80
_____Commuter p.m. (1-4 p.m., Grades 4-9) $80
Amount enclosed____________
Girls/Boys Elite Academy: July 24-27
Cost: $180/Commuter___ or $230/Resident___
Amount enclosed___________Deposit Required $50
REGISTRATION DEADLINE: July 18th
All camps, other than team camps, require a registration form and full payment to
guarantee a spot. After we receive your completed registration form and deposit, you
will be sent a confirmation letter. Your registration will not be processed without the
full payment. Enrollment is limited and sessions will be first-come, first-served basis.
Register online at www.cornellcollege.edu/athletics/camps-clinics/index.shtml or send this
form along with full payment to: Brent Brase, Cornell Athletics,
600 First Street SW, Mount Vernon, IA 52314
Refunds will only be given when we receive a notice from a doctor stating that the
athlete is physically unable to participate in the camp. If this occurs, a
$30 administration fee will be deducted from your refund.