Name of Camper________________________________________ Male/ Female

Date of Birth____________________ Age___________ Home Telephone ____________________

Parent/Guardian _______________________________________

Address _______________________________________________

City ________________________ State _____________________

Zip Code ___________ School_____________________________

Emergency Contact Name and Number________________________________________________

Camper's Sneaker Size __________________________________

Behavior Policy by The Mike Glenn Basketball Camp

The Mike Glenn Basketball Camp for the Deaf promotes a safe, healthy, and respectful environment. We expect campers to behave with the highest character while in attendance. Therefore, we have instituted a policy of zero tolerance for bad behavior and disrespect. Campers are to follow the rules and directions of coaches and other adult camp staff at all times. Campers are to show consideration of others, graciously accept constructive criticism, and consistently try their best. All campers must maintain good hygiene, and pick up after themselves, including sleeping areas, bathrooms, parking lots, all gyms, and basketball court facilities used by the Mike Glenn Basketball Camp. Excessive arguing, fighting, vandalism, theft, or destruction of any property will not be tolerated. Boys and girls will not be allowed in each otherís dorms. Violation of this policy may result in the immediate dismissal of the camper.

Release / Acknowledgement

I hereby grant permission for as parent/guardian for_____________________________to attend the 2019 Mike Glenn Basketball Camp for the Deaf, June 16th - 21st . Please include his or her non-refundable registration fee of $25.00. A late fee of $25.00 dollars will be applied to any late registrations not received by the May 27th due date. Checks and Money Orders shold be made payable to the Mike Glenn Camp. In the unlikely event of an accident, I release the Mike Glenn Foundation, staff, facilities and all volunteers of responsibility. In the event the parent/guardian cannot be reached, I grant permission to have my child treated by a physician, if necessary. My child is physically fit, has medical insurance coverage, and has my permission to participate in all camp activities and travel. If camper has any specific allergies, specific needs or is taking any medication, please note such on the bottom of this form. Please note that all medications must be listed for our foundation to review and approve.

Prescription Medications


Dosage and times taken per day

Hearing Device and ID#
(ie..Cochlear, Hearing Aids...etc)


Signature of Parent/Guardian




The Mike Glenn Foundation for The Deaf and Hard of Hearing

The Mike Glenn Camp for The Deaf frequently has videos and photography taken that may be used on local news, national media outlets, and the Mike Glenn websites. Videos and photographs taken for the Mike Glenn Basketball Camp for the Deaf, or during any outing remains the property of and under copyright to The Mike Glenn Foundation. Please check only one appropriate line

Please check only one
appropriate line

___ I give permission to Mike Glenn Basketball Camp to use any photo(s) or video(s)
images of my son or daughter for the purpose of marketing.

___ I do not give permission to Mike Glenn Basketball Camp to use any photo(s) or
video(s) image of my son or daughter for the purpose of marketing

I have read, understand and agree to the terms and conditions set forth in this registration agreement and to the details included on the information pages.

Name of Camper _________________________________________, Male / Female

Signature ______________________________________

Signature Parent/Guardian ________________________________, Date:___________

Please return permission form and registration fees to your Coach or mail to the address below by May 27, 2019

Mail all forms and registration fees to:
Mike Glenn
P.O. Box 390313
Snellville, GA 30039-0313