REGISTRATION EMERGENCY CONTACT INFORMATION

CAMP INFORMATION
CAMP TIME: 8:00 AM TO 3:30 PM
(GYM WILL BE OPEN AT 7:30 AM FOR DROP-OFF)
AGES: 7 – 16, BOYS and GIRLS
FEE: $200
(FEE INCLUDES LUNCH, T-SHIRT AND AWARDS)
REGISTRATION
CAMPER’S NAME:
AGE:
PARENT NAME:
CELL:
PARENT EMAIL:
T-SHIRT SIZE (CIRCLE 1):
YS
YM
YL
AS
AM
AL
AXL AXXL
EMERGENCY CONTACT INFORMATION & AUTHORIZED GUARDIAN PICK –UP:
NAME
RELATIONSHIP TO CAMPER
PHONE NUMBER
These are the only individuals authorized by the parent to pick-up their child from the FCS Basketball Camp. (Photo ID Required)
COACHING STAFF: The coaches are committed Christians who desire to provide children with the
opportunity to learn about a sport with a Christ-like and Christ-centered perspective.
FOR MORE INFORMATION: Call Jason Doan at: 305-226-8152 X260 or at j.doan@floridachristian.org
PAYMENT INFORMATION: Make Checks Payable to Florida Christian School and return form along
with applicable fee of $200 to:
FLORIDA CHRISTIAN SCHOOL
4200 SW 89 AVE.
MIAMI, FLORIDA 33165
ATTN: JASON DOAN
PARENTAL PERMISSION: I, the undersigned, being the parent or legal guardian of the above named child,
give my consent for the above named child to participate in all activities sponsored by the FCS Basketball Camp.
I also give permission for FCS staff to obtain qualified medical and/or emergency personnel to administer
necessary first aid in the event of injury to my child. I understand that the possibility of injury is inherent in
participation in athletic practices and games. I also understand that neither FCS nor anyone connected to FCS will
assume any responsibility for accidents, medical or dental, or other expenses incurred as a result of accidents
sustained during participation in the FCS Basketball Camp.
I also certify that my son/daughter has had a physical examination in the past year and that no physical limitations
whatsoever were found that would prohibit his/her participation in practices and games conducted by FCS.
PHYSICIAN’S NAME:
PHONE:
INSURANCE RELEASE: I, the undersigned, being the parent or legal guardian of the above named child, do hereby
certify that we carry accident, health, and hospitalization policy on our child who is a candidate for participation in the
Florida Christian School Elementary Basketball Program. I have confirmed with our insurance agent that under the
terms of the policy, injuries incurred by our child during any participation as a member of the aforementioned team are
covered by the policy.
INSURANCE PROVIDER:
POLICY NUMBER:
PHONE NUMBER OF INSURANCE AGENT:
STATEMENT OF AGREEMENT: I have read the above information and it is my desire for my child to participate in
the FCS Elementary Basketball program. I understand that cooperation with the policies of the school, including but not
limited to the general spiritual goals, is a condition for participation in the program.
SIGNATURE OF PARENT/GUARDIAN:
DATE: