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Quarterback and Receiver Camp - Register Now!

Camper Information
Name:
Address:
City:
State:
Zip:
Phone:
Date of Birth:
Social Security #:
High School:
Position:
Grade in September:
T-Shirt Size:
Preferred Roommate
Last Name:
First Name:
Roomate's School:
School Information
Name of School:
Team Name:
School Address:
City:
State:
Zip:
School Phone Number:
Head Coach Last Name:
First Name:
Legal Guardian
Guardian Last Name:
First Name:
Relationship to Camper:
Home Number:
Work Number:
Cell Number:
Fax Number:
Guardian Email:
Emergency Contact (other than above)
Emergency Contact Name:
Relationship to Camper:
Home Number:
Work Number:
Cell Number:
Insurance Information
Insurance Company:
HMO/PPN/PPO:
Policy Holder:
Policy #:
Group #:
Consent to Treatment:
In the event of injury/illness, I give the certified athletic trainers and physicians associated with Bobby Bentley quarterback receiver camp permission to evaluate and treat me. In the event that I am unable to communicate my wishes, the sports medicine staff has my permission to take whatever measures they deem prudent and necessary in a life-threatening or potentially life-threatening situation.
Camper Name:
Date:
Parent/Guardian Name:
Date:
I understand that I am required to bring and submit a copy of my insurance card when I get to camp.
Medical History
Are you currently taking any medications? If so, please list below.
Are you allergic to any medications? If so, please list below.
Are you allergic to any insects? If so, please list below.
Do you have any recent injuries or surgeries? If so, please list below.
List any other medical conditions that we need to be aware of while you are at camp.

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