Loya Basketball, LLC
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Camps
Dates and Cost
REGISTRATION
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Printable Registration Form
* Please send payment along with form.
Online Registration
* Register here and pay below or in webstore.
Athlete's Name
Camp(s)
Skills Camp (July 2-6) $60.00
Playmaker Camp (July 23-27) $100.00
Next Level Camp - Salisbury (July 20-21) $50.00
Next Level Camp -Johnstown (August 3-4) $50.00
Total Owed
Athlete's Gender
Male
Female
Athlete's Grade
4
5
6
7
8
9
10
11
12
Athlete's School
Athlete has insurance
Yes
Insurance Name
Parent(s) / Guardian(s) Name
Email Address
Address
Contact Number
Emergency Contact Name
Emergency Contact Number
Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the athlete prescribed an inhaler? If yes, please explain any instructions.
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Loya Basketball Camps during the selected camp. In exchange for the acceptance of said child’s candidacy by Loya Basketball Camps, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Loya Basketball Camps. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against Loya Basketball Camps. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball.
Yes
Medical Release, Video/Picture Use and Authorization As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to Loya Basketball, LLC. and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. I hereby give permission for my child to be photographed/video recorded while at camp. I give permission for photos and video taken at camp to be used on the website, social media accounts, or local advertising. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Yes
I assume Financial Responsibility for registered athlete. I understand this non refundable.
Yes
Confirmation: BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date
SUBMIT
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