Name of Camper________________________________________

Camper's Sneaker Size __________________________________

Parent/Guardian _______________________________________

Address _______________________________________________

City ________________________ State _____________________

Zip Code ___________ Home Telephone ____________________

Daytime or Emergency Phone _____________________________

I grant permission for my child, _____________________________to attend the 2010 Mike Glenn Basketball Camp for the Hearing Impaired, June 20th - 25th . 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 due date. 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, needs or is taking any medication, please note such on the bottom of this form.

____________________________________________________________________
Signature of Parent/Guardian

____________________________________
Date