Regents Athletics Summer Camp Registration Form

Summer Camp Registration Form

Please complete and submit the following form.
Student Information
Student Name*

First NameLast Name
Student Birthdate*

MonthDayYear
Student Grade*
School*

RegentsHomeschoolOther
Basketball | Greer Elementary School

Varsity Camp ($150)- Boys & Girls Ninth through Twelfth Grades
June 17-21 :: 8:30-11:30am

Middle School Camp ($150)- Boys & Girls Fourth through Eighth Grades
July 15-19 :: 8:30-11:30am

Volleyball | Covenant Church of God

Camp ($150)- Fifth through Twelfth Grades
July 22, 23, 25, & 26 :: 3:00-6:00pm
Camp*
Parent/Guardian Information
Parent/Guardian Name*

PrefixFirst NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Name

PrefixFirst NameLast Name
Phone Number

Area CodePhone Number
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Medical/Emergency Information
Allergies*
Physician Name*
Physician Phone Number*

Area CodePhone Number
Preferred Hospital*

UVA Medical CenterMartha Jefferson Hospital
Complete this section to include an emergency contact different from or in addition to the parent/guardian listed above.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Student-athletes must have the following documents on file:
- Contact & Release Form
- Camp Waiver
Once forms are completed and signed, they can be uploaded below.
Upload a File

Cancelof
Upload a File

Cancelof
Payment
prevnext( X )
Camp Registration$150.00

Total $0.00
Electronic Signature*

I understand that checking this box constitutes a legal signature confirming that, to the best of my knowledge, I have provided accurate information.
Should be Empty: