Whitman Hanson Athletics
Home of the Panthers!
www.whathletics.com

A Summer of Fun for our Future Panthers

The school nurse may not be present during before, after school, or extra curricular programs

Student Information

First Name *

Last Name *

Grade as of September 2025 *

Age at Camp Time *

Date of Birth *

T Shirt Size *

Please check which Clinic(s) you would like to register for *

Co-Ed June 23-27

Boys Basketball July 7-11

Girls Basketball Camp July 14-18

Parent/Guardian Information

Parent/Guardian Name *

Address 2

Town *

State

Zip

Email Address *

An email confirmation will be sent upon receipt of your registration form.

I give permission for my son/daughter to participate in the WH Athletic Clinic. I agree to hold Whitman-Hanson, Bob Rodgers, Mike Costa, all coaches, clinic counselors, officials, trainers and agents free from any liability whatsoever in the event of any type of injury or illness; I also certify that my son/daughter has been through a physical examination within the last 13 months and that he/she is healthy and able to participate in the clinic. I also give my permission for the program to seek medical attention for my son/daughter in the event of an injury, but again will not hold the camp, its coaches, Whitman-Hanson Regional School District or its agents liable for said medical care or lack there of. I understand that he school nurse may not be present for this program.

Phone

Allergies *

My child has the following medical condition that may require immediate attention (911) at school sponsored or activities practice/events that occur outside of the regular school day. *

Does your child Require Epinephrine? *

Does Your Child Require an Inhaler? (If yes, be sure their name is written clearly on it). *

BASIC ACTION PLAN TO FOLLOW - UNLESS PARENT PROVIDED INDIVIDUAL ACTION PLAN: Allergic Reaction: Symptoms include - Difficulty breathing, shortness of breath, wheezing, difficulty swallowing, hives, itching, swelling of any body part, and vomiting. ACTION - CALL 911 AND ASSIST THE STUDENT IN USING AN EPINEPHRINE AUTOINJECTOR IF PRESCRIBED AND AVAILABLE Asthma: Symptoms include - Difficulty breathing, wheezing, and shortness of breath. ACTION - IF THE STUDENT HAS THEIR INHALER, ALLOW THEM TO USE IT. IF NO RELIEF OF SYMPTOMS IN 5 MINUTES CALL 911. IF NO INHALER IS AVAILABLE, CALL 911 IMMEDIATELY. Diabetes: Symptoms of Low Blood Sugar include - Hunger, sweaty, pale, feels shaky, and headache ACTION - ALLOW STUDENT TO DRINK JUICE, EAT GLUCOSE TABS OR FAST ACTING CARBOHYDRATE FROM THEIR EMERGENCY PACK. HAVE STUDENT TEST THEIR BLOOD GLUCOSE LEVEL AND RECORD THE NUMBER. IF NO CHANGE IN SYMPTOMS IN FIVE MINUTES CALL 911 AND HAVE THE STUDENT REPEAT ALL OF THE ABOVE. Seizure: Altered consciousness, involuntary muscle stiffness or movements, drooling/foaming from the mouth, temporary halt in breathing, loss of bladder control. ACTION - GUIDE STUDENT TO THE FLOOR TO PROTECT FROM FALLING, AND CALL 911. NEVER PUT ANYTHING INTO THE STUDENT’S MOUTH. Parent/Guardian child-specific instruction for any of the above action plans - include the location of emergency medication: *

Insurance Type & Number *

Date *

Parent/Guardian Signature (by typing my name I agree that this will represent a valid electronic signature)

Please bring a signed copy of this form with you on the first day of the clinics. ALSO, please include a copy of a recent Physical Exam.

Payment Information

Send checks to ("Panther Basketball Clinic" Whitman-Hanson Regional High School, 600 Franklin Street, Whitman, MA 02382; Please send $25 deposit to hold your spot or you can pay full fee of ($250 for full day camp and $150 for half day camp). (Checks are made payable to WH Basketball - all proceeds from our clinics go to our basketball teams).