Student Information

First Name *

Last Name *

Grade as of September 2023 *

Age at Camp Time *

Date of Birth *

T Shirt Size *

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

Co-Ed June 19-23

Boys Basketball July 10-14

Girls Basketball Camp June 26-30

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 understand that no nurse will be on staff. I agree to hold Whitman-Hanson, Bob Rodgers, all coaches, clinic counselors, officials, trainers and agents free from any liability whatsoever in the event of any type of injury or contraction of Covid 19; 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 am aware that attending this program could put family members at risk in terms of the transmission of Covid 19. I affirm that I understand these risks and will not hold Whitman-Hanson Regional School District, its employees, its agents or any other party liable for any issues that may arise as a result of attending 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. *

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).