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1999 APPLICATION

NOTRE DAME SUMMER

BOYS BASKETBALL CAMP ASTHMA

Joyce Center

University of Notre Dame

Notre Dame, IN 46556

(219) 631-8788

JUNE 15-20 * JUNE 22-27

Fax applications will only be accepted within

7 days prior to beginning of camp

CONSENT TO TREATMENT

LIMITATION AND WAIVER OF LIABILITY

In partial consideration of our child's acceptance into the Notre Dame Summer Basketball Camp, I/we as parents and/or legal guardians of

do hereby agree to limit the liability of the Notre Dame Summer Sports Camps, the University of Notre Dame, its employees, agents, officers, staff and physicians, to the coverage of the medical insurance policy covering participants in the Notre Dame Summer Sports Camps as explained in this brochure, which we have read and understand. I/we further agree to waive all liability of the Notre Dame Summer Sports Camps, the University of Notre Dame, its employees, agents, officers, staff and physicians, for any accident, injury (including death), illness or other mishap which might befall the above-named camper while traveling to or from, or during his attendance at the Notre Dame Summer Sports Camps, which is not covered by said medical insurance policy.

Further, I/we hereby grant permission to the staff and physicians of the University of Notre Dame, any medical or surgical consultant deemed advisable, and any hospital to render to the above-named camper any medical and surgical treatment that they deem necessary. I/we understand that all possible effort will be made to inform me/us in case of such treatment.

PARENT OR LEGAL GUARDIAN's NAME (printed)

SIGNATURE

PHONE: Day

PHONE: Emergency

Night

PLEASE DO NOT USE STAPLES

FOR OFFICE USE ONLY:

 

 

DR

cc

CK#

CAMPER'S HEALTH FORM

 

To be completed and signed by camper's parents or legal

guardians

El HEAD INJURY/CONCUSSIONS

El BLEEDING DISORDERS El HEART DISEASE

CONVULSIONS/SEIZURES El RHEUMATIC FEVER

El DIABETES

ALLERGIES TO DRUGS

ALLERGIES TO FOODS -

LAST TETANUS IMMUNIZATION (date):

CURRENT MEDICATIONS:

CHRONIC OR RECURRING ILLNESSES:

OPERATIONS/I NJ U RIES (including dates):

PHYSICAL RESTRICTIONS*:

PHYSICIAN TELEPHONE

DENTIST TELEPHONE

MEDICAL INSURANCE

POLICY NUMBER

PARENT AUTHORIZATION/

RELEASE OF INFORMATION

This health history is correct to the best of my knowledge and my son/daughter has my permission to participate in camp activities with the exception of those noted above*.

I authorize University of Notre Dame Health Services to release medical information regarding the above named participant to interest parties including parents and family physician.

PARENT OR LEGAL GUARDIAN MUST SIGN

Please Read Carefully and Retain fo

SITE:

The setting for the Notre Dame Basketball Camp is the nationally renowned campus of the University of Notre Dame, located on the outskirts of South Bend, Indiana, 90 miles east of Chicago on the Indiana Toll Road. All campers will reside in one of the residence halls normally occupied by undergraduate students of the university. Meals will be served in the South Dining Hall (nonboarders receive lunch and dinner). Many of the Midwest's finest athletic facilities will be utilized during each camp session.

Your Information

APPLICATION PROCEDURES:

All prospective campers must submit the completed application portion of this brochure. Applications will be processed on a first-come, first-served basis until all sessions are filled. Within seven (7) days of the start of camp, 9"1 fax applications with credit card payment will be accepted. Acceptance of a camper will be verified upon receipt of the camp confirmation packet.

If a camp has been filled prior to the receipt of a camper's application, the camp office will offer you the opportunity to have the application held on a waiting list if desired. If the application cannot be accepted for any reason, the application and camp fee will be returned by mail.

0 m ELIGIBILITY:

Boys who, in June of 1997, will have completed the 5th through the 11th grades are eligible.

DATES & FEES:

M Each camp is of 5 nights' duration and will include a Friday

morning session. There will be two weeks of camp this

summer:

June 13-18 or June 20-25:

BOARDERS: $335.00

 

Includes all meals, lodging, insurance, and t-shirt.

NON-BOARDERS: $275.00

 

Includes lunch and dinner, insurance, and t-shirt.

INSURANCE:

Accidental death and dismemberment coverage is provided according to schedule and with a maximum principal sum of $1,000; medical expense coverage is provided with a maximum of $50,000. Claims up to $250 per claim are paid on the primary basis, without regard to any coverage parents might have. Claims exceeding $250 per claim will be paid on the excess basis, meaning that family or employer group coverage must

 

 

pay its maximum first. This refers to medical expenses incurred because of injury sustained during scheduled and supervised camp activities. Hernias are not covered. The contracting of illness or disease by camper is not covered under this plan. Payment for medication and/or hospitalization needed by camper as a result of illness or disease is the responsibility of the camper and his parents. Any additional coverage desired will also be the responsibility of his parents.

 

TRANSPORTATION:

Discount air fares are available for those needing to fly to South Bend by calling Anthony Travel, Inc. on the campus of the university at 1-800-366-3772. Identify yourself as attending the summer sports camps and save money on flights from most cities throughout the U.S. South Bend is also accessible via Amtrak and major bus lines. Notre Dame is located off the Indiana Toll Road at exit 77.

 

PROGRAM:

Individual and group instruction in all phases of basketball. Special Shirt Size

attention will be devoted to all phases of defensive play as well as

offensive drills in ball handling, shooting, rebounding and passing.

 

Application, Consent to Treatment, and Health Form must be completed and sent along with FULL payment to Camp Office for enrollment.

CAMPER'S NAME: Last

ADDRESS:

Grade in Fall

Outstanding college and high school coaches and college players throughout the country will serve as visiting instructors and counselors. Supervised league play each day with awarding of trophies will highlight the camp's activities. Parents may attend any session and are encouraged to attend and observe the Friday morning session.

The numerous outdoor basketball courts will be utilized along with the climate controlled court in the Joyce Center.

For further information on the Baseball, Girls Basketball, Cheerleading, Football, Hockey, Boys Lacrosse, Girls Lacrosse, Boys Soccer, Girls Soccer, Softball, Swimming and Volleyball Camps, please contact:

Notre Dame Summer Sports Camps

Joyce Center

Notre Dame, IN 46556

Phone: (219) 631-8788 / FAX: (219) 631-8231

Email: ndcamps.l@nd.edu

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First MI

Street

Zip

Height

City i

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9

Telephone

Age (during camp) Sex

Weight

Roommate Request: (not required, but roommate must select you as preference to

guarantee)

Name of School

 

Check FIRST CHOICE of session ONLY: June15-2 June 22-

BOARDER

($335.00)

NON-BOARDER

I ($275.00)

PAYMENT BY: El Check El MasterCard [I Visa

Please make checks payable to the Notre Dame Basketball Camp. Please send check and application to the address on next panel. Checking account debit cards will not be accepted.

CARD #

CARDHOLDER NAME (print)

PHONE:Home

ADDRESS: (If different from above)

Work

EXP.DATE

SIGNATURE

I have read and I understand the camp program and application proce as described in this brochure.

 

PARENT OR LEGAL GUARDIAN MUST SIGN