Girls High School Shootout
June 19-21, 2017
TEAM CAMP REGISTRATION FORM
*CONTACT INFORMATION*
Circle one:
VARSITY
JV
Head Coach’s Name: ________________________________ Tee Shirt Size: ___________
Email: ___________________ Cell Phone: ____________ Work Phone: ________________
Assistant Coach’s Name: _____________________________ Tee Shirt Size: ___________
School: __________________________ School Address: _____________________________
School Phone: _________
*GAME INFORMATION*
*Please check the day(s) you wish to play and indicated the number of games you want for
each day
MONDAY JUNE 19th
Number of Games: __________ X $50.00 = $_________
TUESDAY JUNE 20th
Number of Games: __________ X $50.00 = $_________
st
WEDNESDAY JUNE 21
Number of Games: __________ X $50.00 = $_________
+ Additional $10 per player over the ten player roster
*We are asking for advanced payment to the camp by June 15, in the form of cash or a school cut check. The
first day of camp we will accept cash only at registration (no personal checks from players at registration).
Payment can be sent to:
Drury Women’s Basketball
cc Katie Pritchard
900 N. Benton
Springfield, MO 65802
*If your team is staying on campus, please fill out the “Team Camp Housing Form”
Girls High School Shootout
June 19-21, 2017
Names of Players Attending Camp:
Tee Shirt Size
(Minimum of 8 players recommended)
(1)_______________________________________ ____________________________
(2)_______________________________________ ____________________________
(3)_______________________________________ ____________________________
(4)_______________________________________ ____________________________
(5)_______________________________________ ____________________________
(6)_______________________________________ ____________________________
(7)_______________________________________ ____________________________
(8)_______________________________________ ____________________________
(9)_______________________________________ ____________________________
(10)______________________________________ ____________________________
*There is an additional fee for teams with more than 10 players. ($10 cost for each player over ten)
(11)______________________________________ ____________________________
(12)______________________________________ ____________________________
(13)______________________________________ ____________________________
(14)______________________________________ ____________________________
(15)______________________________________ ____________________________
Return via Email or Fax to:
Katie Pritchard
Assistant Coach
Drury University
[email protected]
Fax: (417) 873-6984
Office: (417) 873-6340
Cell: (573) 528-8090
Drury University Lady Panthers
*CONTACT INFORMATION*
Name: ___________________ Tee Shirt Size: ______ Grade Next Fall: ___
Email: ______________________ Cell Phone: __________________
School: _______________________
Waiver and Release
I/We, the undersigned, for ourselves, our heirs, executors, and administrators waiver, release and forever
discharge Drury University and the Drury Women’s Basketball Camps, its staff, officers, agents,
representatives, employees, successors and assigns of and from any and all rights and claims for dangers
resulting from injury to person or property which may be sustained or occur during participation in camp
activities or arising from traveling to or from the camp, whether said damages, injury or loss is due to
negligence or not.
Medical Release Form
I/We hereby grant permission to Drury University, its physicians and athletic trainers to render aid,
treatment, and medical care deemed reasonably necessary to the health and well-being of my daughter while
in attendance at the Basketball Camp.
Camper Information:
Camper’s Full Name: _______________________________ Birth Date:________________
Last
First
Middle
Allergies: ___________________________________________________________________________________
Is camper presently on any medication (if yes, please specify)? _______________________________________
____________________________________________________________________________________________
List any restrictive physical limitations: ______________________________
Date of last physical:____________________________ Copy of physical included (please circle) YES NO
Emergency Phone Numbers:
Contact Person (Relationship): Phone Number: ________________
Contact Person (Relationship): Phone Number: ________________
Medical Insurance Information:
Company Name: Policy Number: ____________________________
Name the Policy is under: ________________________________________
______________________
_____________
Parent or Guardian’s signature
Signature Date