*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 --Middle School-- Chapel Hill Salem --High School-- Arabia Mountain Martin Luther King Southwest Dekalb --Private School-- Green Forest Green Pastures OTHER 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 any Camp of Champions activities during his/her contracted stay at the day camp.

I hereby give my approval for his/her participation in any activities of the Camp of Champions, Inc. Basketball Camp and After School Program, 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 6:30pm ET.

Parent __________________________ Date __________

All fees are due no later than the first pick-up for the week.
Payments received after the first pick-up will be assessed a late payment charge of $10.00
(A weeks consists of 3 or more days between Monday and Friday)

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

or Bring the forms in person to the Camp Site Location above.

Print 2 copies of the form prior to Submitting