REGISTRATION

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Click for Printable Registration Form

Print out and mail to:

Loya Basketball

P.O. Box 417

Salisbury, PA 15558

Online Registration

* Register here and pay below or in webstore.

Athlete's Name*

Camp(s)*

Skills Camp (June 24-27, 2019) $60.00 Before May 15 or $70.00 after May 15Playmaker Camp (July 22-26, 2019) $100.00 Before May 15, 2019 or $125.00 after May 15, 2019

Total Owed*

Athlete's Gender*

Athlete's Grade*

Athlete's School*

Athlete has insurance*

Yes

Insurance Name*

Parent(s) / Guardian(s) Name*

Email Address - Opting in Loya Basketball email list*

Address*

Contact Number*

Emergency Contact Name*

Emergency Contact Number*

Does athlete have any allergies, chronic illness, or medical conditions? If yes, please describe:

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Loya Basketball Camps during the selected camp. In exchange for the acceptance of said child’s candidacy by Loya Basketball Camps, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Loya Basketball Camps. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against Loya Basketball Camps. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. *

Yes

Video/Picture Use and Authorization: I hereby give permission for my child to be photographed/video recorded while at camp. I give permission for photos and video taken at camp to be used on the website, social media accounts, or local advertising. *

Yes

I assume Financial Responsibility for registered athlete. I understand this non refundable.*

Yes

Confirmation: BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.*

Date *

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Skills Camp

$70.00