PLEASE PRINT CLEARLY AND LEGIBLY
Name:
____________________________________________________________
Address: __________________________________________________________
City:
____________________________________State:
_______ Zip: _________
Home Phone: __________________ Cell Phone: __________________________
Emergency Phone:
__________________ (Other than parent/guardian)
E-mail Address:
_____________________________________________________
School: ______________________________Grade Level
(Fall 2013)___________
Elite
Skills Academy ( Entering Grades 4-9) At The Bishop OÕConnor Center
10:00-11:00 Ball
Handling
11:00-12:00 Shooting
12:00-12:30 Lunch
(Bring your own)
12:30-1:30 Offensive
Skills and Sets
1:30-2:30 Defensive
Skills and Sets
2:30-3:30 Games
June
14th 10:00-3:30
p.m. Session 1 ______ June 14th 100
dollars
June
24th-28th 10:00-3:30
p.m. Session 2
_____ June 24th-28th
325
dollars
Both (1&2) _____ 375
dollars
(
LIMITED
NUMBER OF PLAYERS- RUN SOLEY BY COACH COLLINS)—At the Bishop OÕConnor
Center
Please Read and Sign as to Parental Consent:
In
case of illness or injury, permission is granted to treat the participant at
any appropriate medical facility.
By signing above you are giving consent in advance for medical
treatment. Furthermore, as a
participant in the basketball academy, you hereby state that you are aware of
and accept the risk inherent in the program activity. The above signed does hereby agree to
hold harmless and indemnify the Bishop OÕConnor Center, Stephen Thomas Collins
LLC, Steve Collins Basketball Academy LLC and their officeÕs agents and
employees, as well as coaches, from any and all liability, loss, damage, cost
or expense which is sustained, incurred, or required arising out of the actions
of my dependent in the course of the camp/clinic. I hereby grant permission to
Stephen Thomas Collins LLC and its affiliates to interview, photograph and/or
videotape me or my minor child to use information from the
aforementioned interview, images or videos in educational videos, advertising
and or any promotional materials without compensation. All campers must have their own medical
insurance. Please notify me of any medical needs you may have while at
camp.
Parent/Guardian
Signature: ________________________________ Date: _________________
Send Registration to:
The Academy will be filled on a first come basis.
Steve Collins Basketball Academy
18 Chesterton Circle
Madison WI 53717
Make checks payable to: Steve
Collins