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Player’s Name                                                                                                         Player’s                          Player’s Phone Number

                                                                                                                     Grade

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Parent Name                                                                                            Parent Phone Number

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Address                                                                                                      T-Shirt Size:           S      M      L      XL

 I hereby request that my child be admitted to the Kirksville High School girl’s basketball camp. I hereby authorize and direct the staff to exercise and act in their best judgment in the event of a medical emergency regarding my child. I also hereby confirm that my child is covered by accident and/or health insurance, which provides coverage for any injury. I agree to indemnify and hold harmless Sara Williams, the camp staff, Kirksville School District and its agents and employees, from and liability or action arising from or related to my child’s enrollment and/ or participation in the camp.

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