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Off The Court Behavior Basketball Registration Form - Las Vegas, NV
OTCB Baketball Kamp Registration Fee
*
Quantity
$150
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(First Time) includes annual $50 registration fee & one (1) week of Kamp
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$80
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(First Time) includes annual $50 registration fee & one (1) day of Kamp
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$100
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1 Week returning Kamp participants that have already paid annual fee
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$30
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1 day returning Kamp participants that have already paid annual fee
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Camp Participant Information
Child's Name
*
First Name
Last Name
Child's Primary Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Child's Date of Birth
*
Please enter the child's date of birth
Child's Age
*
Child's age by 06/01/2015
Child's Grade Level
*
Please enter the grade level the child will be attending as of 6/1/2015
Child's Gender
*
Female
Male
Child's T-shirt Size
select one
Child Small
Child Medium
Child Large
Adult Small
Adult Medium
Adult Large
Parent Information
Parent Name
*
Prefix
First Name
Last Name
Suffix
Primary Parent Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Daytime Phone
*
Home Phone
Mobile Phone
*
Email
*
Verify Email
*
Child Resides with:
*
select one
Mother
Father
Both
Primary Emergency Contact
*
Prefix
First Name
Last Name
Suffix
Relationship to child
Primary Emergency Contact Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Primary Emergency Contact Phone
*
Primary Emergency Contact Email
*
Verify Email
*
Secondary Emergency Contact Copy
Prefix
First Name
Last Name
Suffix
Secondary Emergency Contact Address Copy
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Secondary Emergency Contact Phone Copy
Secondary Emergency Contact Email Copy
Verify Email
Relationship to child Copy
Medical Emergency Information
Primary Physician Name
Prefix
First Name
Last Name
Suffix
Physician Address
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Physician Phone
Child Medical Conditions
List any medical conditions the child may have (asthma, diabetes, etc):
List any allergies the child may have (including to medicine):
List any medications the child is currenty taking:
Date of most recent tetanus shot:
(mm/dd/yyyy)
Medical Insurance Company
Medical Plan Number:
Medical Member Number:
Please indicate if your child has any special and/or behvioral needs: