2019 Lady Patriots Basketball Camp
Participant's First and Last Name *
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Date of birth *
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Age *
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Grade entering Fall of 2019 *
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Home Address (include street address, city, state, zip code) *
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Phone *
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Email Address *
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Emergency Contact Name *
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Emergency Contact Relationship to Participant *
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Emergency Contact Phone *
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Family Physician Name *
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Family Physician Phone *
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Insurance Company Name *
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Insurance Company ID # *
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Insurance Company Group # *
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Insured's Name *
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Insured's Phone *
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List any allergies *
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T-shirt size *
Payment Options *
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