2019 Reggie Stovell Basketball Summer Camp in Hakuba
Student Details
First name *
Your answer
Last name *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Gender *
Home address *
Your answer
1st language *
Your answer
2nd language
Your answer
School currently attended *
Your answer
Grade as of July 2018 *
Your answer
Height in cm *
Your answer
Weight in kg *
Your answer
Parents / Guardian Details
Name of parent / guardian *
Your answer
Relationship to student *
Contact e-mail *
Your answer
Contact e-mail (confirmation) *
Your answer
Home phone number *
Your answer
Parent/guardian's mobile phone number *
Your answer
Student Health Information
Is student in good health? *
Is he/she allergic to anything? (e.g. penicillin, antibiotics, aspirin, bee/wasp stings, shell fish, nuts, strawberries, etc.) *
If he/she has allergy, please specify below.
Your answer
Does he/she suffer from asthma, hay fever or any other chronic conditions? *
If yes, please specify below.
Your answer
Does he/she take any medication? *
If yes, please specify below.
Your answer
Does he/she require any special diet? *
If yes, please specify below.
Your answer
Transportation options
We ask the parents / guardian to accompany the child to Hakuba. Free pick up from within Hakuba Village to the venue is provided. In case the child needs to travel unaccompanied, please consult with us. You can also have your child travel to/from Hakuba with Reggie using Shinjuku-Hakuba express train. Please specify your choice of transportation.
Transportation to Hakuba on July 15th *
Transportation from Hakuba on July 19th *
Other Information
I found out about this camp from: *
Required
Is there anything else we should know about your child’s health or learning aptitude so that he/she can benefit fully from his/her stay at the basketball camp?
Your answer
DECLARATION AND AGREEMENT
I declare that the information given above is correct. I have read and understood the “General Information” and “Conditions of Acceptance” including the cancellation policy as set out on the basketball camp web site and I agree to the terms. In the event of accident or emergency, I authorise the camp organiser to make decisions regarding the care of my child as may be necessary at the time.
I hereby agree with the following:
1. I am aware that the insurance does not cover non-accidental dental treatment or pre-existing medical conditions and that insurance covers a maximum of JPY 3 million.
2. I will not hold the camp organiser responsible for accidents caused by my child, and I will be responsible for damages caused by my child to a third party.
3. I understand that the basketball camp is likely to be covered by the media (including but not limited to newspapers and TV) and there is a chance that images of my child may appear in the media. Also, I give authorization to the camp organiser for use of images and movies taken during the basketball camp for the promotion of the event and the venue.
4. I understand that information about my child provided to the camp organiser will be used solely for the purpose of operating the basketball camp. I allow the camp organiser to provide information to the insurance company for the purpose of insuring my child during the camp.
I agree to the terms above. *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service