Team Name: ____________________________________________________________________________________________

Address: _______________________________________________________________________________________________

City: ___________________________________________ State: _________________ Zip: ____________________________

Head Coach Cell/Contact #: ________________________________ Fax: __________________________________________

Coaches E-mail Address__________________________________________________________________________________

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

 ***MAKE ALL CHECKS PAYABLE TO: Jose Fernandez Basketball Camp

Team Camp - June 25-27 , 2010

___ 1 team $500.00  ___ 2 teams $475.00 each   ___ 3 teams $450.00 each   ___ 4 teams $425.00 each

Additional material and acknowledgement of your registration will be mailed to you upon receipt of your application and non-refundable deposit.

Mail completed Application and checks to:

Univesity of South Florida

Attn: Jose Fernandez Basketball Camps

4202 East Fowler Ave, SUN 141

Tampa, FL 33620

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 Company: ________________________________________ Policy #: _________________________

Subscriber’s Name: _______________________________________ Phone #: __________________________________

Pre-authorization required by company YES ___  NO ___