*First Name *Last Name

*Address *City *State * Zip

D.O.B *Age *Gender Male Female

* Home Phone

Father's Name Work Ph# Cell/Pager#

Mother's Name Work Ph# Cell/Pager#

Special Health Conditions/Allergies

Emergency Contact

Name Phone #

Name Phone #

School Name --Elementary-- Austin Rd (Henry Co) Bob Mathis Bouie Brownsmill Cedar Grove Chapel Hill Fair View (Henry Co) Midway Narvie J. Harris Oak View Rainbow Wadsworth --Middle School-- Chapel Hill Salem --High School-- Arabia Mountain Martin Luther King Southwest Dekalb --Private School-- Green Forest Green Pastures Grade Pre-K K 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Teacher

Release Information:
I, authorize Camp of Champions and it's contracted transportation company to transport,
to and from the designated locations (listed below) starting on .

We need to be notified no later than 12:00 noon if your child will not be picked up in the afternoon from school

I hereby give my approval for his/her participation in any activities of the Camp of Champions, Inc. Basketball Camp and/or After-School Hours Basketball Camp, held at Camp Site:

and authorize staff persons of the Camp of Champions, Inc. to provide guardianship for him/her while participating in Camp of Champions activities.
I assume all risks and hazards incidental to such participation, including transportation to and from the activities, and do hereby waive, release, absolve, indemnify and agree to hold harmless the Camp of Champions, Inc., the organizers, sponsors, supervisors, participants, staff persons, and person transporting my child to or from activities, for any claim arising out of injury to my child.

I agree to pay the Camp of Champions, Inc a late fee in cash upon pick-up if pick-up is made after 6:30pm ET.
At 6:31pm ET a fee of $5.00 is required and $1.00 for each additional minute beyond 6:31pm ET.

Parent __________________________ Date __________

NOTE: If you are a CAPS recipient, please contact Coach D for pricing and rate sheet.

After-School Hours Basketball Camp Fees include Transportation :
All fees are due upon pick-up at the beginning of the week.
Payments received after the beginning of the week will be assessed a late payment charge of $10.00

The After-School Hours Basketball Camp coincides with the DeKalb County School Calendar.

Contact Coach D at CCI for pricing.

Make all check (s) & Money Orders Payable to:
Camp of Champions, Inc.
All return checks will be charged a $25.00 service fee.

Additional Comments:

Please complete the form, print, sign, date and mail to the following address with your check.

Camp of Champions
P.O. Box 361531
Decatur, GA 30036-1531

Print the form prior to Submitting