Please print this page and fill out the forms and sign. Mail both forms to the address below. DION GLOVER FOUNDATION P.M Box 181 3653-F Flakes Mill Road Decatur, Georgia 30034

Dion Glover Basketball Camp Registration Form NAME: _____________________________________________________________________ AGE: _________ ADDRESS: __________________________________________________________________________________ PARENT/GUARDIAN: ________________________________ PHONE(H) ______________ (W) ______________ IN CASE OF EMERGENCY, CONTACT: _________________________________ PHONE: ____________________ SIGNATURE OF PARENT/GUARDIAN: __________________________________________ T-SHIRT SIZE: (Adult Sizes)          S         M         L         XL         XXL         (CIRCLE APPROPRIATE SIZE) SESSION: JULY 27-30          (FILL OUT BOTH FORMS - DETACH - RETURN WITH PAYMENT) (any blanks not filled in may result in the return of this application)

RELEASE FOR MEDICAL TREATMENT Name: _________________________________________________________ Date: ____________________ List any conditions that physicians should be aware of _________________________________________________ ___________________________________________ Allergies ________________________________________ Phone number of emergencies: Home: ______________________ Work: _______________________ I hereby authorize any medical treatment which may be advised by the attending physician of (Camper's name) _________________________________________________ while at Life University, Marietta, GA, INSURANCE COVERAGE for accidental injury is required of all camp participants. I have insurance through _________________________ My Policy number is _______________ It is understood that an injury may result from camp participation. I hereby release Life University, Dion Glover and Dion Glover's Staff & Dion Glover Foundation from any and all claims which might arise from my child's participation in the Dion Glover Basketball Camp. Parent or Guardian Signature __________________________________ Home Phone ______________________ Address _______________________________________________ Work Phone ___________________________