Team Name:
Coach Name:
Cell Phone:
Coach Home Address:
Street
City
State
Zip Code
Coach’s Email Address:
Choose your division (Circle One):
Rate your team for competition level:
Team Camp
Date:
Time:
Location:
Cost:
Format:
JV
V
AAU
1-4 (4=Highest Level)
June 30, 2017
Approx. start 8am
Last game start 8pm
Belk Arena in Baker Sports Complex on Davidson College Campus
BEFORE May 1st - $150.00 Team Fee plus $25.00 per player
AFTER May 1st - $175.00 Team Fee plus $25.00 per player
*(Each team will be charged for at least 8 players)
Teams will receive 3 games unless otherwise noted when registering. High school
rules will be in effect and certified referees will be officiating the games.
* The Team Fee is due by June 9th
* You must fill out a Medical Release Form for every player that will be attending OR submit a copy of
current school physical within 1 year and a parental release form.
*MAKE ALL CHECKS PAYABLE TO: MICHELE SAVAGE LLC
I am enclosing the required completed Roster Form along with our check in the amount of
$_____________ to reserve our spot for ______# of teams.
All Players are required to complete a registration form and have their Physician Medical
Waivers completed and submitted with the Teams information by June 9th.
Checks payable to: Michele Savage, LLC
Return by Mail:
Return By Fax
Return By Email
Davidson Women’s Basketball Camp
Attn: Kira Mowen
534 Lorimer Rd
Davidson, NC 28036
Attn: Kira Mowen
704-894-2556
Kira Mowen
[email protected]
Davidson Women’s Basketball Camp
Medical Waiver
Must be signed by a physician and received by
June 9th to participate
PHYSICIAN’S STATEMENT
I hereby certify that I have examined,
_________________________________________
(Camper’s Name)
and have found her physically fit to attend and participate in the 2017 Davidson Women’s Basketball Camp.
_____________________________________________
(Physician Name)
_____________________________________________
(Address)
_____________________________________________
(Phone)
_____________________________________________
(Physician Signature)
PARENTAL PERMIT
The law requires parental permission be obtained for operative procedures on minors. The following consent form should be signed
by the parents so that such proceedings may be promptly carried out, and so that no unnecessary delays will occur with operative
procedures. However, no operation will be performed, except emergency, without parents being fully contacted and informed.
I give my permission for such diagnostic therapeutic and operative procedures as may be deemed necessary for my daughter.
I, the undersigned, hereby acknowledge and understand that the Davidson Women’s Basketball Camp is a privately run sports camp
and is not operated by or through Davidson College. The camp is not sponsored, controlled nor supervised by Davidson College, but
rather it is under the sole sponsorship and supervision of the Camp Director, Michele Savage.
I hereby state that the Davidson Women’s Basketball Camp is not responsible for any pre-existing injury or recurrence of any
undisclosed illness of the above-mentioned camper prior to onsite registration. Davidson Women’s Basketball Camp will assume
responsibility only for injuries incurred while the above camper is participating in camp activities under supervision during the
enrolled camping period. I understand that once a camper is enrolled in camp there will be no refunds given for sickness or injury.
PHOTO RELEASE
I assign and grant permission for the Davidson Women’s Basketball Camp to use and publish any photographs taken during the
camp.
__________________________________________
(Signature)
_______ ___________________________________
(Date)
_______________________________________
(Street Address)
______________________________________
(City, State, Zip)
_______________________________________
(Relationship to Camper)
______ ________________________________
(Cell Phone #)