Waiting List

Registrant's Name *

First

Last

Email Address (All event communication will be sent to this e-mail address) *

Confirm Email

Street Address *

Address Line 1

Address Line 2

City

State

Zip Code

Grade (as of Fall 22) *

Cell Phone *

Home Phone

Age (at time of camp) *

School *

Heigth *

Shirt Size *

Parent or Legal Guardian Name *

First

Last

Parent or Legal Guardian Email Address *

(All event communication will be sent to this e-mail address)

Parent or Legal Guardian 2 *

First

Last

Parent or Legal Guardian Email Address 2 *

(All event communication will be sent to this e-mail address)

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact Relationship *

Name of Health Insurance Company *

Insurance Mailing Address *

Insurance Policy Number *

Group Number (if applicable)

Policy Holder's Name *

Policy Holder's Date of Birth (m/d/y)

Policy Holder's Relationship to Participant *

Policy Holder's Employer

Does your camper have any allergies? *

If so, what is your camper allergic to?

Dietary Restrictions

Does your camper have any physical or medical conditions that we should know about? *

If so, what is the condition and what is the current treatment?

Is your camper currently taking any medication? *

If so, what is the medication and dosage?

Relationship to Camper *

Are you a University of Memphis Student?

Check *

I accept the Penny Hardaway Basketball Camps Waiver of Liability

Waiting List