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Registration Application
PLEASE PRE-REGISTER AS SOON AS POSSIBLE.
There is limited space, and this will help assure a spot for the week of your choice.
Please complete the registration form and the “Medical Treatment Authorization Form" below.
The cost per week (including camp shirt) is
$77.00 per person, first week
$70 each for siblings, first week
$70 for 2nd and 3rd weeks
Please make checks payable to
"Kevin O'Leary"and mail to him at:
Before May 15:
202 Addington Dr.
Deland FL 32724
After May 15:
P.O. Box 1475
Center Harbor, NH 03226
For assistance, call: (239) 249-9276 or email olearycamp68@gmail.com
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Registration:
Child's Name:
Address:
Phone:
Parent/Guardian Name:
Parent/Guardian Email
Week of Attendance:
Additional Week:
*For a third week, contact Kevin at 239-249-9276
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Camp Dates, Times and Ages
June 24 – June 28
Ages 12-14 - 8:30 am – 11:30 am
July 8 – July 12
Ages 9-11 – 8:30 am – 11:30 am
July 15 – July 19
Ages 12-14 – 8:30 am – 11:30 am
July 22 – July 26
Ages 9-11 – 8:30 am – 11:30 am
July 29 – August 2
Ages 12-14 – 8:30 am – 11:30 am
August 5– August 9
Ages 9-11 - 8:30 am – 11:30 am
x
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Medical Treatment Authorization Form
I am a parent or guardian of a child participating in recreational activities of the Town of Merrimack. I recognize that children at play and involved in recreation are sometimes injured and sometimes injured seriously. It may be necessary for medical care to be requested and provided before it is practical to contact the parent or guardian. Accordingly, I authorize the agents of the O'Leary Basketball Camp to in turn authorize physicians, hospitals, nurses, EMTs and other medical personnel to look after my child as they see fit until such time as I can be contacted.
I am the Participant’s parent and legal guardian. By printing my name below, I signify that I have read this form and understand its terms. I executed freely and voluntarily with full knowledge of its significance.
Child's Name:
Parent Name:
Emergency Phone Number:
-OR-
I am the Participant’s parent and legal guardian. I have read this form and understand its terms. I decline to give my permission as outlined above with full knowledge of the significance of this decision.
Child's Name:
Parent Name:
Emergency Phone Number:
# # #
Submit Registration:
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