The 2012 Jim Calhoun Basketball Camp

Camp Information and Parental Consent Form

Mail To:

The Jim Calhoun Basketball Camp
c/o Gold, Orluk & Partners
P.O. Box 1177, Avon, CT 06001-1177

Please fill in completely. The form cannot be accepted without signatures.

Camper Name:	Address:
City:	State: Zip:
Country:	Roommate Requested:
Parent/Guardian Email (Required):	Home Phone:
Parent/Guardian Cell Phone:	Parent/Guardian Work Phone:
Height:	Weight: Grade Entering in Fall of '12:
Birthday:	Type of Camper: (Check One)     Commuter or Resident

CANCELLATIONS: NO REFUNDS WILL BE GRANTED AFTER JUNE 1ST, 2012. THE $200 NON-REFUNDABLE DEPOSIT WILL BE DEDUCTED BEFORE ANY REFUND IS MADE PRIOR TO THAT DATE. PARTIAL REFUNDS WILL BE GRANTED FOR ONLY MEDICAL REASONS WITH A SIGNED PHYSICIANS EXCUSE. NO REFUND WILL BE GRANTED FOR ANY REASON AFTER JUNE 1ST, 2012. All cancellations must be in writing, email or fax and will not be accepted over the phone.
I HAVE READ AND UNDERSTAND THE CAMP REQUIREMENTS:

_______________________________ Parent/Guardian's Name(s)

_______________________________ (Parent/Guardian's Signature - only one)

I hereby authorize any medical evaluation or treatment which may be advised or recommended by the attending physician of _____________________________ while at the Jim Calhoun Basketball Camp. WAIVER AND RELEASE AS REQUIRED BY THE JIM CALHOUN BASKETBALL CAMP FOR ALL CAMPERS: In consideration of my application being accepted, intending to be legally bound, do hereby, for myself, my heirs, executors and administrators, waive, release and forever discharge any and all claims for damages, which I may or which may hereafter occur to me, against The Jim Calhoun Basketball Camp and The University of Connecticut or their respective officers, agents, representatives, successors and/or assigns, for any or all damages which may be sustained or suffered by me in connection with my association with or participation in on the campus of The University of Connecticut. I, the parent or guardian, do hereby agree to the above waiver and release.
I HAVE READ AND UNDERSTAND THE CAMP POLICY:

________________________________ Parent/Guardian's Name(s)

________________________________ (Parent/Guardian's Signature - only one)