all fields are required.
—Please choose an option—MaleFemale
Cell/Work Phone #
Cell / Work Phone
Physician’s Phone #
I certify that my child "camper" is in good health and has my permission to participate in all training activities, practices, games and camp activities at the Chuck Driesell Basketball Academy. I hereby give permission to the Chuck Driesell Basketball Academy Inc, its officers, employees, agents, athletic trainers or staff members to take whatever action is necessary for the health and welfare of my child including consenting on my behalf to any and all medical /dental treatment, procedures, operations and or hospitalization needed.
I understand that basketball is a very physical sport, which can result in serious injury. I hereby Release and Hold Harmless the Chuck Driesell Basketball Academy Inc, its officers, employees, agents, trainers and staff members, with respect to any and all injury, liability, disability, death, loss or damage to person or property that may result from or occur during the camp week. I
further agree to hold any of them harmless and indemnify them for all medical/dental bills incurred for the treatment of my child.
Parent / Guardian’s Printed Name
Parent / Guardian’s signed name