Women's Basketball Clinic

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Student Biographical Information

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Student Preferred First Name (if different)

If a preferred name is provided, we will use it in all communications including physical mailings to your mailing address.

Student Last Name

Birthdate

Student Contact Information

Student Email Address

Please note that there is an opportunity at the bottom of this form to provide a parent/guardian email address for communication purposes. The "Student Email Address" should be unique to this student.

Student Mobile Phone Number

Student Mailing Address

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Student Academic Information

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Current (or most recent) School

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Graduation Year

Basketball Clinic Information

T-Shirt Size

Basketball Position

Would you like to take a campus tour after the clinic?

Payment Information

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Emergency Contact Information

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First Name Last Name Relation to Student Other Email Address Phone Number Can the participant be released to this person?

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List additional adults the participant may be released to (if applicable).

Health Information

List any food, medication, or environmental allergies.

List any medications currently being taken, their dosages, and the reason for that medication.

List any orthopedic injuries within the past year. Please include the nature, severity, and date of the injury.

Family Physician

Physician Phone Number

Health Insurance Company

Health Insurance Group and Policy Numbers

Name of Person who is Primary Policy Holder

Health Form E-Signature

With my e-signature below:

I verify that all of the above information is accurate to the best of my knowledge.
I authorize Elizabethtown College and the clinic athletic training staff hired to provide medical treatment for my child.
I verify that my child may participate in any and all camp-related activities and events, and that my authorization does not conflict with any medical advice or concerns expressed by my child’s physician.

E-Signature

Indemnity Release and Waiver E-Signatures

I hereby acknowledge that participation in the Camp may involve physical and recreational activities and that these activities may involve risks including, but not limited to, the following:

Physical exertion, such as: lifting, spotting, holding, catching other individuals; lifting equipment; running, quick movements; climbing; balancing; and stretching exercises.
Risks inherent to participation in sports and other recreational activities, such as: being hit or struck by equipment; rough, physical contact with other participants.

I realize that it is not possible to list specifically each and every risk. However, knowing the material risks and appreciating, knowing and reasonably anticipating that injuries, illness, paralysis and even death are possible, on behalf of my minor child, I hereby expressly assume all such risks that could occur by reason of his/her participation in any activities and the use of facilities and equipment related to the Camp.

I agree that, in exchange for and in consideration of the College permitting my minor child to participate in the Camp, I hereby agree to forever release, Elizabethtown College, its trustees, officers, agents, and employees, from any cause of action, claims, or demands of any kind and nature whatsoever including, but not limited to, claims for negligence or any other form of action for which a release may be legally given (including attorneys’ fees and costs) which may arise by or in connection with my minor child’s participation in any activities related to the Camp.

I further covenant not to sue and agree to hold harmless and indemnify the College, its trustees, officers, agents and employees from any and all liability, causes of action, claims, demands, losses or costs of any kind and nature whatsoever (including attorneys’ fees) arising out of or in any relating to my minor child’s participation in any activities or his/her use of the facilities or equipment related to the Camp.

I understand that while participating in the Camp, my minor child must follow the instructions and directions provided by College personnel and that he/she must abide by the policies of Elizabethtown College. Failure to follow instructions or directions may result in my minor child’s immediate expulsion from the Camp.

E-Signature

I hereby authorize Elizabethtown College to act on my behalf in any medical emergency.

E-Signature

I hereby grant permission to the College to videotape or photograph my minor child and to use and display such videotapes or photographs publicly (including on the College’s website) for educational, promotional, or any other purposes in furtherance of the non-profit missions of the College.

E-Signature

Clinic Schedule

12:00 - 12:45pm		Player Arrival at Thompson Gymnasium
1:00 - 4:00pm		Player Clinic in Thompson Gymnasium a. Drills demonstrated by current team b. All drills and instruction given by current coaching staff
4:00 - 4:45pm		Campus Tour

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Women's Basketball Clinic

* indicates a required field

If a preferred name is provided, we will use it in all communications including physical mailings to your mailing address.

Please note that there is an opportunity at the bottom of this form to provide a parent/guardian email address for communication purposes. The "Student Email Address" should be unique to this student.

Begin typing the name of your school and select it from the dropdown.