Name: ____________________________________________________________________________________________
Address: ___________________________________________________________________________________________________
City: ___________________________________________ State: _________________ Zip: __________________________________
Home Phone: ____________________________ Age at Camp: _______T-Shirt size: ____________ Grade Fall 2010:__________
E-mail Address: ______________________________________________________________________________________________

Elite Camp: June 28-29, 2010 (Grades 9-12)

A non-refundable deposit of $100 is needed to process application. Balance is due at registration.

Player Medical Release Form

All campers must have their own medical coverage. Campers will not be allowed to play unless the following information is submitted. This form must be signed by the parent or guardian of the camper.

Name of Applicant: ___________________________________________________
Camper Insurance Co.: ________________________________________ Policy #: ___________________________________________
Subscriber’s Name: _______________________________________ Phone #: ______________________________________________
Pre-authorization required by company YES ___  NO ___ 

Medical Treatment Authorization

I/we the undersigned, for ourselves, our heirs, executors and administrators, waive, release and forever discharge the USF Basketball
Camp and it’s staff, officers, agents, employees, representatives, successors and assignees of and from all rights and claims for
damages, injuries, or lost of person propriety which may be sustained or occur during participation in camp activities or while at camp.

Signature __________________________________________________ Date ________________

Balance due for all campers at registration.

Please make checks payable to: Jose Fernandez Basketball Camp.
Mail application to:

University of South Florida

Attn: Jose Fernandez Basketball Camp
4202 E. Fowler Ave., SUN 141
Tampa, Florida 33620

For more information regarding individual camp, contact Andy Alwood at              (813)-974-9859 or aalwood@admin.usf.edu