2007 Lane Lord’s Basketball Camp
Registration Form



Name____________________________________________________________

Address_________________________________________________________

City_______________________________________State________________

Zip_____________________________________________________________

Phome Number (___)______________________________________________

Email Address___________________________________________________

School__________________________________________________________

Coach________________________________________07-08 Grade________

Emergency Name__________________________________________________

Emergency Number (___)__________________________________________

Camp Options

Option 1: Overnight Camp w/10 meals -- $225
After May 25th -- $240__________________________________________

Roommate preference_____________________________________________

Option 2: Day Camp w/7 meals -- $190
After May 25th -- $205__________________________________________

Option 3: Day Camp w/out meals -- $160
After May 25th -- $175__________________________________________


PARENTAL RELEASE
I hereby authorize the staff of Lane Lord’s Girls Basketball Camp to act for me according to their best judgment in any emergency requiring medical attention and hereby waive and release Lane Lord’s Girls Basketball Camp, the Kansas Board of Regents, Pittsburg State University, and all employees and agents from all claims on account of any injury or illness sustained by my child while attending above said camp.

________________________________________________________________
Signature of Parent / Guardian                                                       Date

Insurance Company_______________________________________________

Address_________________________________________________________

Policy Holder Hame______________________________________________

Policy Number___________________________________________________

Youth T-shirt Size:    S    M    L

Adult T-shirt Size:    S    M    L    XL