NAME_________________________________________AGE_____ HT._____ WT._____ GRADE (NEXT YEAR)___________

ADDRESS____________________________CITY/STATE_____________________________ZIP________

E-MAIL ADDRESS____________________________________________________

SCHOOL_____________________________________________COACH'S NAME______________________________________

SCHOOL ADDRESS______________________________CITY/STATE____________________________ZIP________

CHECK ONE: (   ) POST PLAY CAMP   (   ) POINT GUARD CAMP   (    )  PERIMETER PLAY CAMP
(   ) BOY (   ) GIRL

I hereby request my son, daughter or ward be admitted to the SHOOTING STARS BASKETBALL CAMP for boys/girls and authorize the Camp Directors to act for me according to their best judgment in any emergency requiring medical attention for which services I shall pay.

PARENT/GUARDIAN SIGNATURE______________________________________________PHONE: _________________________

Mail Application and $100 deposit to: SHOOTING STARS BASKETBALL CAMP, 849 N. GARFIELD AVE., DELAND, FL 32724