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1998 JERRY TARKANIAN BASKETBALL CAMP PLEASE PRINT CLEARLY Please Check the Session You Wish to Attend. Name Age _ Entering Grade M/F T-Shlrt Size: Mens S M L XL Boys Offensive/Defensive Individual Improvement Camp Mother/Guardian June 22-24 - 9 am to 4 pm - Grades 4 thru 12 $150.00 Bus.Phone Home Phone El Boys Offensive/Defensive Individual Improvement Camp Father/Guardian June 29-July 2 - 9 am to 4 pm - Grades 4 thru 12 $175.00 Bus.Phone Home Phone Address NOT LINE 1-800-364-1634 city State_ Zip School Medical Insurance Co. ID# _ Medical Conditions we should be aware of I hereby authorize the staff of the Fresno State Basketball Camp to act for me in their best judgment in any emergency requiring medical attention and I hereby waive and release Me Camp from any and at/ liability for injuries or Illnesses Incurred while at camp. I ha ve no knowledge of any physical impairment that would be affected by the above named camper's participation in the Camp program. I also understand the Camp retains the right to use for publicly and advertising purposes, photographs of campers taken at Camp. Application will not be processed without signature. Parent/Guardian Signature Charge It! Please charge amount authorized to my credit card. 11 Visa El Master Card El Discover $ Exp. Date Cardholder's Name Card Number Cardholder's Signature Make Checks Payable to: Fresno State Basketball Camps Mail Checks to: 5305 North Campus Drive, Fresno, California 93740-0027 Your canceled check is your receipt |