Building Up Sports Academy, Inc Registration Form
CHILD’S NAME:______________________________________ SEX: M F
D/O/B: ____________ AGE ___________ GRADE_________
PARENT/GUARDIAN: __________________________________________________________________
HOME
ADDRESS______________________________________________________________________
CITY:__________________________ ST:_____________ ZIP:____________
HOME PHONE:_______________________ CELL: _________________________________________
WORK PHONE:_______________________
E-MAIL ADDRESS ______________________________
EMERGENCY CONTACT_________________________ PHONE#________________________
OTHER CONTACT_______________________________ PHONE#________________________
WILL ANYONE OTHER THAN YOU BE PICKING UP YOUR CHILD?YES____ NO____
IF YES, PLEASE IDENTIFY:_____________________________________________________________
IS YOUR CHILD ALLERGIC TO ANY FOODS? YES____ NO____
IF YES, PLEASE LIST AND EXPLAIN_____________________________________________________
PLEASE CHECK CAMP:
______BASEBALL CAMP JULY 26-29, 2010 $250.00
______BASEBALL CAMP AUG 2-5, 2010 $250.00
______ FISHING CAMP JULY 26-29, 2010 $350.00 1 PM - 4 PM
______FISHING CAMP AUG 2-5, 2010 $350.00 9 AM - 12 PM
______FISHING CAMP AUG 2-5, 2010 $350.00 1 PM - 4 PM
______FISHING CAMP AUG 2-5, 2010 $675.00 (full day camp 9 AM - 4 PM)
TOTAL$____________
PLEASE MAKE CHECKS OUT TO BUILDING UP SPORTS ACADEMY, INC. AND MAIL THE
REGISTRATION FORM WITH CHECK OR MONEY ORDER TO P.O BOX 222981, WEST PALM BEACH ,
FL 33422. FOR REGISTRATION QUESTIONS , PLEASE CALL 561-601-5248.
WAIVER OF LIABILITY: I hereby declare that I am the parent/guardian of ______________________
And give my consent for his/her participation in all Building Up Sports Academy, Inc summer camp
activities. In consideration of my child being permitted to participate in these activities, I hereby release,
waive and discharge The Building Up Sports Academy, Inc, The Town Of Nantucket, employees and
volunteers from all liability for injury, loss, or damage, and any claim of damage to the person or property
of my child during his/her participation. It is further that any false information provided for in this
registration form will cause denial of participation. All cancellations must be made 2 weeks prior to the
camp/activity. No cancellations will be accepted once camp has begun.
PRINT NAME____________________________ SIGNATURE____________________DATE______