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            Basketball Camp Application


Darelle Porter / Duquesne Dukes 1999 Summer Basketball Camps Application

Last Name                                                          First Name      Age                   Height      Weight

Street Address                                        city      State                  Zip               Home Phone ( )                         Parent Business Phone ( )

School Entering                                                                  Grade ( ) in the Fall                                                   Coach


Please note any specific medical conditions or allergies to medications



Name of Parent or Guardian Health Insurance Group # Health Insurance I.D. #

RE: WEEKEND CAMP - Only (2) persons to a room. Please be specific and be sure roommate is coming to camp. If a name is not listed, 2 roommate will be assigned by the basketball office. Roommate's name: _________________________________________________________________________________________________________

I have enclosed a check payable to: DARELLE PORTER / DUQUESNE DUKES BASKETBALL CAMP for:

__ $130.00 Weekend Overnight Shooting Camp (June 18-20) ___ $ 50.00 deposit enclosed

(Dads $75. additional))

__ $165.00 First Day Camp (June 28 - July 2) - ___ $ 50.00 deposit enclosed

__$165.00 Second Day Camp (August 2 - 6) - ____ $ 50.00 deposit enclosed

Mail To: Darelle Porter / Duquesne Dukes Basketball Camp, Duquesne University, A.J. Palumbo Center, Pittsburgh, PA 15282- For more information, call Basketball Office (412) 396-6567.

The undersigned parent/guardian understands that the applicant will be engaging in physical activity during the program which contains an inherent risk of physical injury and the undersigned assumes this risk and releases the Darelle Porter / Duquesne Dukes Basketball Camp, as officers, director, agents and employees from any and all liability for personal injury arising out of the applicant's participation in the basketball camp program.

I hereby grant permission for my son to attend the above mentioned camp and be treated by a licensed physician or a member of the athletic training staff during the event of any injury, accident, illness or other mishap.

Parent/Guardian Signature                                                                                                                              Date

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