Camp #1
June 16 -19

Please print this page and complete all information. When completed send signed form and payment of $195
to 5 Star Athletics, 29605 Thrasher Court, Mechanicsville, MD 20659. Your spot in camp is not guaranteed
until registration AND payment are recieved. A confirmation email will be sent once the payment/registration
has been verified.

Athlete’s Name ______________________________

Parent/Guardian Name ______________________________

Street Address ______________________________

City ______________________________

State ______________________________

Zip Code ______________________________

Daytime Phone ______________________________

Evening Phone ______________________________

E-Mail Address ______________________________

Date of Birth ______________________________

Age ______________________________

Emergency Contact Name ______________________________

Emergency Contact Phone ______________________________

Known Allergies ______________________________

Current Illnesses or health problems ______________________________

Current Medications ______________________________

Physician’s Name ______________________________

Physician’s Phone ______________________________

Health Insurance Company ______________________________

Policy # ______________________________

I have read and agree to the following waiver:

“I certify that my child has no injury or illness that would limit participation in the camp and has had a physical examination in the past year. I authorize 5 Star Athletics and the camp staff to act for me according to their best judgment in any emergency requiring medical attention. I hereby waive and release 5 Star Athletics and their staff from any and all liability for any injury or illness incurred while at the camp or on the way to and from camp. I have medical coverage and will be responsible for any expenses resulting from injury, illness, or accident incurred during the camp. I grant authority to the first aid and CPR certified trainer on site to provide necessary and reasonable medical attention to my child.”

Signature ____________________________________ Date____________________________

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