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Hawks Fall Basketball Registration Grades 4-6

Program Information

The cost of the program is $165. The program will run on Friday nights during the months of September and October. The dates are September 16, 23, 30 and October 7, 14, 21, and 28.

4th grade boys will attend from 5:30-6:20 pm.

4th-6th grade girls will attend from 6:30-7:20 pm.

5th and 6th grade boys will attend from 7:30-8:20 pm.

Please complete the player registration form.

Player's First Name

Player's Last Name

Home Phone Number

Address

City

State

Zip Code

What school does the player attend?

What grade is the player entering in Fall, 2022?

Fourth Grade

Fifth Grade

Sixth Grade

How did you hear about our program?

What size shirt does the player wear?

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

What is the name of an emergency pickup person?

What is the phone number of the emergency pickup person?

Mother's First Name

Mother's Email Address

Mother's Last Name

Re-enter Mother's Email Address

Mother's Cell Phone Number

Father's First Name

Father's Email Address

Father's Last Name

Re-enter Father's Email Address

Father's Cell Phone Number

Medical History Information

Does Your Child Have Any Allergies

Does your child have an epi-pen?

Yes

No

Does your child have diabetes?

Yes

No

Does your child have a heart problem?

Yes

No

Does your child have scoliosis?

Yes

No

Has your child had stitches recently?

Yes

No

Please list any daily medications:

Does your child have health insurance?

Yes

No

What is your family physician's name?

Does your child have asthma?

Yes

No

Does your child have a seizure disorder?

Yes

No

Does your child have a neurological problem?

Yes

No

Has your child had surgery recently?

Yes

No

Has your child had a bone fracture recently?

Yes

No

Please list the approximate date of your child's last physical exam.

What is the name of your health insurance carrier?

What is the address of your family physician?

What is your family physician's phone number?

Emergency Procedures

Please accept all terms for your child to attend camp.

Yes, I agree, that in case of an accident or serious illness to my child, I request program directors to contact me.

Yes, I agree, that if the program directors are unable to reach me, I hereby authorize the program directors to call the physician listed and follow his/her instructions.

Yes, I agree, that if it is impossible to contact my physician, my child should be transferred to the nearest emergency room.

Yes, I authorize that the emergency room physician may assess, diagnose and treat in order to provide comfort to my child.

I require that surgical intervention will require parent or guaridan permission unless the illness is life threatening.

Yes, I certify that my child is in good health and give permission for his/her participation in Hawks Game Camp.

Yes, I authorize emergency and medical treatment which may be needed in the event of an injury that the emergency room physician may assess, diagnose and treat in order to provide comfort to my child.

Yes, I understand that my primary insurance coverage is my own responsibility through my individual or family plan.

Yes, I agree to defend, indemnify and hold harmless Hawks Game Camp, Princeton Charter School and instructional personnel in the event of injury to my child.

Yes, I hereby give Hawks Game C permission to use photographs and videos of my child for marketing materials including the website.

The cost of the program is $165.

$

Thanks for submitting!

Coach Aaron (609) 240-4033

Located on the Princeton Charter School Campus

100 Bunn Drive, Princeton, NJ 08540

Coach Mark (215) 630-4092

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