2021 Summer Basketball Camp Registration Form

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First Name of Camper *

Last Name of Camper *

Date of Birth *

YYYY

Age *

Grade (Entering in fall 2021) *

Gender *

Male

Female

Parent(s)/Guardian(s) Name(s) *

Mailing Address *

City *

State *

Zip Code *

Phone Number *

Email *

Please check the weeks your child will attend camp. *

$65 per week, $110 for both weeks - Camp runs from 9am-11:30am each day

Week #1: June 28 - July 2 (Rain Dates: Saturday, July 3rd and Monday, July 5th)

Week #2: August 2nd - August 6th (Rain Dates: Saturday, August 7th and Monday August 9th)

Both Week #1 & Week #2

Required

Please list any medical conditions we should be aware of including asthma and allergies:

Payment, documentation of physical, and any other items can be mailed to:

Dan Korte
65 Mandalay Rd.
Lee, MA 01238

Balance due 1st day of camp - Checks made out to: “LYA”

Documentation of a physical exam completed within the past 13 months is required by the first day of camp.

Waiver (Required)

I, the parent/guardian of the above named camper, understand and accept the condition that no one associated with the camp will assume any responsibility for accidents and medical expenses as a result of participating in the camp. The applicant is in good health and is able to participate in the physical activity of the rigorous program. I hereby authorize the director of the camp to act in an emergency requiring medical attention for my son/daughter.

Electronic Signature *

Submit

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