CAMPER MEDICAL INFORMATION
Medical Insurance Company
_______________________________________________
Policy Number
_____________________________________________
Medical conditions we need to know:
_______________________________________________
Allergies ___________________________________
Medications__________________________________
PARENT/GUARDIAN AUTHORIZATION: I
certify that I have received any and all information that I deem necessary for my child to participate in the Pike County Basketball Camp identified in this brochure. Also I agree to assume all
risks of his/her participation in the program’s activity and agree to hold harmless Pike County
Schools, Pike County High School, its employees
or volunteers against any liability clams, damages
or expenses arising from my childs participation
in the Pike County Youth Basketball Camp. Finally, I authorize the staff of the Pike County
Youth Basketball Camp to secure any emergency
medical treatment necessary to treat my child in
event that is deemed necessary by the staff of the
Pike County Youth Basketball Camp,
Signature of Parent/ Guardian
_______________________________
Date_____________
Boys and Girls
Pirate Youth
Basketball
Camp
at PCHS GYM
June 27th - 29th, 2017
9:00 am - 1:00 pm
Ages 6 yrs. - 8th grade
Reserve Your Spot
Today!!!
Mail or Deliver Registration and
Check to:
Pike County High School
Attn: Coach Habelt
331 Pirate Drive
Zebulon, GA. 30295
Boys and Girls
Pirate Youth
Basketball
Camp
at PCHS GYM
June 27th - 29th, 2017
9:00 am - 1:00 pm
Ages 6 yrs. - 8th grade
Reserve Your Spot
Today!!!
Mail or Deliver Registration and
Check to:
Pike County High School
Attn: Coach Habelt
331 Pirate Drive
Zebulon, GA. 30295
CAMP REGISTRATION FORM
CAMP T-SHIRT included
Please enroll my child
Name__________________________
CAMP FEATURES
All will participate in
daily fundamental
activities and games
with coaches, pirate
players and current
college players.
Camp Leaders:
Address
______________________________
______________________________



Coach Greg Green

Coach Eric Habelt


Checklist
Basketball shoes
Socks
Shorts
T-Shirt
Money for concessions/lunch
Swimsuit and Sunscreen on
Thursday
Mindy Habelt
Pirate Alumni
Current Boys and Girls Players
Phone # where parent can be
reached______________________
T-shirt size S M L XL
circle one:
Youth
Questions text:
Coach Habelt 404-357-9631 or
email : [email protected]
Adult
Grade__________ (for next school year)
Cost $60 ($30 for 2nd child)


S M L XL
Make checks payable to Lady Pirates Tip-Off
Club
____ paid cash
____ paid check
*Please complete front and back of form