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  1. APPLICATION OBJECTIVEOF NBN BASKETBALL CAMP NAME__________________________ GRADE (Fall ’09)___ AGE_____________ T-Shirt Size_____ PARENT/S NAME__________________________________ ADDRESS________________________________________ CITY___________________ ZIP___________________ PHONE___________________ WORK#________________ Have you had an illness or injury in the past year? Y or N Are you currently taking any prescription or over the counter medications or using an inhaler? If yes, list them aside. Y or N _________________________________ Do you have any kind of allergies? Y or N Have you ever been told you have a heart murmur or other cardiac condition? Y or N Has a physician ever denied or restricted your participation in sports? Y or N Are you a diabetic? Y or N Have you ever had a head injury, concussion or seizure? Y or N Do you have asthma or seasonal allergies that require medication? Y or N Do you use any protective equipment or braces? Y or N Do you have any vision or hearing problems? Y or N Have you ever had a sprain, strain or swelling after injury? Y or N Are your immunizations current? Y or N To teach basketball skills with individualized instruction and progress to a team concept. The starting point is learning how to shoot, dribble, pass, etc. FOR:Boys and Girls (ages 7-12) LOCATION:R.N. Harris Elementary School 1520 Cooper Street Durham, NC 27703 DATES:June 21st – 25th 2010 TIME: 9:00am - 4:00pm Extended care is available from 8:00am – 8:45am & 4:00pm – 5:00pm COST:$85.00 Extended care is $5.00 a day. CONTACT:Reggie Parker – Camp Director (919)672-7897 (vm) email: WHAT TO BRING:Campers must bring a a bag lunch for Mon.-Thursday. Lunch will be served on Friday. T-shirt, shorts and sneakers must be worn everyday. Early Registration ends June 7th 2010. In the event of injury, illness or other condition that in the judgment of the camp staff needs medical care, I hereby give my consent for the camp staff to obtain such care to be given. I consent to the signing of any releases by the camp staff which may be required by any medical provider and to the release of any information required by the medical provider or insurance companies. I understand that participation of my child/ward in the camp is at sole risk of my child/ward. I assume that risk and hereby indemnify and hold harmless the NBN Basketball Camp and all staff members and employees from all cost, damages or other liability arising from any acts or omissions that may occur while my child/ward attends the camp. I understand that NBN Basketball Camp is a privately run camp and is not operated, sponsored, controlled or supervised by or through the elementary school, but is under the sole sponsorship, control and supervision of the camp director, Mr. Reggie Parker. I understand that the tuition is $85 a week or $110 if I opt for extended care. A $30 charge will be added for all returned checks. A $20 late fee will be added every 30 min after 5:00pm pickup. If notification is not received two weeks prior to the opening of camp, no refunds will be made. I have enclosed a check or money order made payable to NBN Basketball Camp. At 825Waring Street Durham, NC 27704 PARENT/GUARDIAN SIGNATURE:______________________________________________________