Hoops with Heart - Registration Form
This is a registration and consent form for children PreK - 8th Grade to participate in a Free Basketball Camp hosted by WV Health Right and the City of Charleston. Please register by March 15th.

When: Sunday, March 27, 2022
  1:00 - 2:30pm: PreK - 2nd Grade
  3:00 - 4:30pm: 3rd - 5th Grade
  5:00 - 6:30pm: 6th - 8th Grade
 
Where: King Community Center, 314 Donnally St. Charleston, WV 25301

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Your Full Name *
Participant Full Name *
Shirt Size for Participant *
Grade of Participant *
Home Address
Phone Number (mobile)
Does the participant have health insurance?
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If yes to insurance, please list insurance provider
Emergency Contact Name and Phone Number *
Participant's Primary Care Provider
Participant's Dentist
Do you give consent for WV Health Right staff to treat your participant if illness or injury occurs? *
By signing this registration form you, the guardian or responsible party for the registered child, understand that you release WV Health Right, The City of Charleston, and any associated sponsor or other participant from liability of any injury or illness that may occur including possibility of COVID-19 *
Signature* (Type your name) *
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