DiverseCity Hoops - Pittsburgh - Session 3
DiverseCity Hoops Summer Basketball Camp - Session 3
Boys and Girls Entering Grades 5 - 9
July 22 - July 26
Location: Western Pennsylvania School for the Deaf (WPSD)
9AM - 3PM
Camper Information
Camper Last Name *
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Camper First Name *
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Gender *
Birthday *
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Grade (entering next school year)
School *
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Parent/Guardian Information
Parent/Guardian First Name *
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Parent/Guardian Last Name *
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Second Parent/Guardian First Name
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Second Parent/Guardian Last Name
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Phone *
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Alt. Phone
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Address *
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City *
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State *
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Zip Code *
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Email *
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Confirm Email *
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Camper Email (optional)
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Health Insurance Information
Please note: We DO NOT provide health and/or medical insurance. Campers must rely on their parent/guardian's medical services. Insurance information must be included on this application. Minor sports injuries will be treated by an on-site athletic trainer. DiverseCity Hoops waives all responsibility for treatment of camp related injuries.
Please note any medical conditions we should be aware of:
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Health Insurance Provider
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Agreement #
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Policy #
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Agreement
I hereby authorize the staff of DiverseCity Enterprises, Inc. to act for me in accordance with their best judgment in any emergency requiring medical attention and I hereby waive and release the camp from any and all liability for any injuries or illness incurred while at camp. I have no knowledge of any physical impairment that would be affected by the above named camper's participation in the camp program, as outlined on this website.

DiverseCity Enterprises, Inc. has my permission to use photographs and/or video recordings of my child publicly to promote its programs. I understand that the images and/or video may be used in print publications, online publications, presentations, websites, social media and other similar forms of use. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

I understand and agree to all terms of the application mentioned above. *
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