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Sign up for Kirksville boys basketball camp

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WHEN: May 30th – June 2nd (Tue-Fri) Turn in all Forms by May 12th for Guaranteed Shirt WHERE: PRIMARY GYM (Enter West Doors) Camp is open to all Kirksville and surrounding area

Camp Staff will be Coaching Staff/Former Current Players (Alumni) 9th-12th Must be from boys attending KHS

GRADES/TIMES:

GRADES (boys entering) 3rd -5th 8:00 – 9:30 AM $40.00

GRADES (boys entering) 6th-8th 10:00 – 11:30 AM $40.00

GRADES (boys entering) 9th-12th 12:30-2:30 $40.00

CAMPER INFORMATION

NAME: _________________________ GRADE FOR 2017-18: __________ AGE: _____ BIRTHDATE: __________

ADDRESS: _____________________ CITY: _________________ ZIP: _______ HOME PHONE #: __________________ EMERGENCY #:

SHIRT SIZE (circle): Youth: 10-12 14-16 Adult: S M L XL XXL (When in doubt on sizes, order a size too big as we do not order extra shirts!)

**Identification and Medical Treatment Authorization**

The undersigned parents and/or guardians of (campers name) ____________________, the applicant, for and in further consideration of the basketball camp acceptation said applicant, does hereby release and discharge Kirksville R-III Schools and it’s representatives, employees, and agents from any and all debts, claims, demands, actions, damages, caused of action, judgments, or suits of any kind which may arise or be occasioned as a result of any course of instruction or the applicants participation in the basketball camp. In addition, I/we being the parents and/or guardians of the applicant authorize the Kirksville R-III and its agent’s permission to request emergency medical treatment or care as necessary to insure the well being of our dependent. Further, I claim the registrant has had a physical examination in the past year and was found fit for all physical endeavors.

Signature of Parent or Guardian: _________________________ Date: ____________________

Family Health Insurance Provider: ____________________________________________________

Family Health Insurance Policy #: _____________________________________________________

**Camper Code of Conduct Contract**

As a participant in the Kirksville Tiger Basketball Camp, I agree to comply with all of the rules, regulations, and directives of the coaching staff, and I will treat all of the coaching staff and other camp participants with respect, courtesy, and good will. I have read the above statement and understand that failure to comply with that statement may result in my removal from the camp without refund.

Participants Signature: _________________________ Date: _______________________

For additional information contact Tyler Martin by email at tmartin@kirksville.k12.mo.us

Mail Camp Form and Fee to: Attention: Tyler Martin

KIRKSVILLE HS 1300 S Cottage Grove OR Ray Miller Elementary 2010 E Normal

Make Checks Payable To TIGER BASKETBALL

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