PARENT OR GUARDIAN INFORMATION

HOME PHONE:
Parent/Guardian must sign: Date: , 2014
SIZE
What to Bring: Lunch/snacks, water bottle, reversible jersey (or light
and dark t-shirts), and a basketball if possible.
Collection and Use of Personal Information
This personal information is being collected in accordance with the Municipal
Government Act and is protected by the privacy provisions of the Freedom of
Information and Protection of Privacy Act. Program registrations are entered
into our basketball database. The information will not be sold or used except
for Rising Stars Basketball's purposes.
Camp Contact/Head Coach:
Brett Jakubec
BOX 557, Viking, Alberta T0B-4N0
Phone: (780) 336-6023
Fax: (780) 336-2503
Email: Gjakubec95@gmail.com
Facebook: Rising Stars Basketball Camps
OPTION #1: GR. 7 - 9 JR. HIGH BOYS PRICE: $175
DATES: AUG. 11-15, 2014 (MON. - FRI.)
TIMES: 9:00am - 10:30am and 12:30pm - 2:00pm
CHECK BOX
OPTION #2: GR. 10 - 12 SR. HIGH BOYS PRICE: $175
DATES: AUG. 11-15, 2014 (MON. - FRI.)
TIMES: 10:45am - 12:15pm and 2:15pm - 4:00pm
CHECK BOX
Participants are accepted on a first-come first-serve basis.
Fax or email completed registration forms to the contact info. listed below.
RISING STARS BASKETBALL CAMP WILL BE HELD AT VIKING SCHOOL IN VIKING, ALBERTA
CAMP T-SHIRT INCLUDED - SELECT SIZE
YOUTH: L, XL or ADULT: S, M, L, XL
REGISTRATION DEADLINE: JULY 20, 2014
LAST NAME:
ADDRESS:
CITY/PROV:
POSTAL CODE:
MEDICAL HISTORY: (Please list any medical conditions that staff shoud be aware of.)
FIRST NAME:
Rising Stars Basketball Camps
CELL PHONE:
FIRST NAME: LAST NAME:
EMAIL ADDRESS (IF DIFFERENT FROM ABOVE):
2014 Registration Form - Jr. and Sr. High BOYS Basketball Camp
DOB: MM ______ DD ________ YEAR _______
PARTICIPANT INFORMATION
IN CASE OF EMERGENCY, CALL:
GRADE ENTERING IN FALL OF 2014:
EMAIL:
AB HEALTH CARE #:
CELL PHONE:
Registration FEES must be received by the registration deadline to confirm spot.
NOTE: ALL refunds are subject to an administration fee of $50.00 - unless a Doctor's medical note is provided.
I acknowledge that Rising Stars Basketball is NOT responsible for any injury incurred.
CHEQUES PAYABLE TO: BRETT JAKUBEC