BYRON SAMUELS RADFORD UNIVERSITY BASKETBALL CAMP
APPLICATION

Make check payable to: Think A.H.E.A.D., Inc.
Return to: Byron Samuels Basketball Camp
Radford University
P.O. Box 6913
Radford, VA 24142
(540) 831-5125

NAME____________________________________________
STREET__________________________________________
CITY_________________________STATE____ZIP________
HOME PHONE______________________________________
SCHOOL__________________________________________
GRADE NEXT YEAR_________________________________
HT___________WT__________ DOB___________________
PARENT'S WK PH#_________________________________
PARENT'S CELL PH#________________________________
I have___have not___ earned an athletic letter since entering the ninth grade (check one).

I will:
______ Board on campus

______ Attend as day camper

T-shirt size: SM___ MD___LG___ XL___XXL___

$50.00 DEPOSIT REQUIRED
A registration fee of $50.00 must accompany this application. The fee is non-refundable and will be credited toward the tuition fee of $250.00 boarding/$185.00 day. The remaining balance must be paid by cash, personal check or money order on the first day of camp at registration. All campers must complete and return the application, waiver and release form and the medical release form in order to participate in camp.

Parent/Guardian Signature_______________________________

Office Use Only:
Amt. Paid_______ Bal. Due________D_____B_____

WAIVER AND RELEASE
We, the undersigned, for ourselves, our heirs, executors and administrators waiver, release and forever discharge the Byron Samuels Basketball Camp, or Think A.H.E.A.D., Inc., its staff, officers, agents, representatives, employees, successors and assigns of and from any and all rights and claims for dangers resulting from injury to person or property which may be sustained or occur during participation in camp activities, or arising from traveling to and from the camp, whether said damages, injury or loss is due to negligence or not.

Parent/Guardian Signature_______________________________

CAMP MEDICAL RELEASE FORM

I/we hereby grant permission to Radford University, its physicians, and athletic trainers to render aid, treatment and medical care deemed reasonably necessary to the health and well-being and I additionally grant, when necessary for protecting the health and well being of:

(Name of Camper) ___________________________________________
has permission for hospitalization, treatment or surgery at a competent
and/or accredited facility.

Campers birth date___________________________________________

Allergies:__________________________________________________

Is camper presently on any medication?__________________________
_________________________________________________________

Does camper have any restrictive physical limitations?
_________________________________________________________

Home Phone Number_______________________________________

Home Address____________________________________________

________________________________________________________

Parent/Guardians Name/Work Phone Number:
________________________________________________________

Medical Insurance Name and Number:
________________________________________________________

Name/Phone Number of Friend/Relative if Parent/Guardian cannot be contacted:
________________________________________________________

Date____________________________________________________

Parent/Guardian Signature___________________________________
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