Regents Athletics Summer Camp Registration Form

Summer Camp Registration Form

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

First Name Last Name
Student Birthdate *

Month Day Year
Student Grade *
School *

Regents Homeschool Other
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 *

Prefix First Name Last Name
Phone Number *

Area Code Phone Number
E-mail *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent/Guardian Name

Prefix First Name Last Name
Phone Number

Area Code Phone Number
E-mail
Address

Street Address

Street Address Line 2

City State / Province

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

Area Code Phone Number
Preferred Hospital *

UVA Medical Center Martha 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 Name Last Name
Emergency Contact Phone Number

Area Code Phone 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.
Payment
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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: