School Break Camp(s)

SCHOOL BREAK CAMPS

Boys & Girls Grades K - 4

October 3

October 14

9am - 12pm

@ Kulture HHK

Child's Information

First Name *

Last Name *

Gender *

Grade *

Schools Out Camp - $75 per day

3.5% credit card convenience fee
*

Thursday Oct 3

Monday Oct 14

Parent Contact

Relationship to Participant: *

Mother

Father

Guardian

First Name *

Last Name *

Address *

City *

State *

Zip

Cell Phone *

Email Address *

Comments

WAIVER: I hereby authorize the staff of Goats Basketball to act for me according to their best judgment in any emergency requiring medical attention for my child, if I cannot be contacted. In consideration of acceptance of my child, I hereby for myself, my child, theirs heirs, executors and administrators hold harmless, waive and release any claim we may have for damages against the above mentioned organizations, camp operators, their officials, officers, employers or representatives, or their successors and assigns for any and all injuries that may be suffered. I certify that I am parent/guardian of above participant and I am over the age of 18 years. I further agree that the above named parties are under the obligation to provide a physical examination or other evidence of a child's fitness to participate in this program, the same being my sole responsibility. I attest that my child is in sound condition to participate in all activities. I understand by signing this waiver any or all refunds will come in the form of camp credit. SIGN BELOW: *

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