2021 FAS Bruins Camp Registration

Name of Camper *

First

Last

Name of Parent / Guardian *

First

Last

Grade (2021-22 School Year) *

School *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Disclaimer / Policy Statement *

I have read and understand the Disclaimer / Policy statement below *

I, the undersigned, being the individual, spouse, or legally authorized and qualified guardian of the student named, agree to hold Bartlesville Public Schools, it's Board of Trustees, administration, and/or faculty, harmless from all liability for any injuries which my son/daughter may receive while participating in recreational activities or utilizing the Bartlesville School District facilities. I hereby authorize the athletic director, coach and/or district employee to secure medical services for any family memberif necessary, and I agree to pay either directly or through my own personal health and accident insurance policy all medical costs

Street Address of Signing Parent / Guardian

Address Line 1

Address Line 2

City

State

Zip Code

Parent / Guardian Name *

First

Last

Father's Place of Employment

Mother's Place of Employment

Family Physician *

Family Physician Address *

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Company

Insurance Policy Number

Camp to be attended *

Camp T-Shirt Size *

PLEASE NOTE **** ONLY THOSE CAMPERS WHO ARE PRESENT, ONTIME, AND SIGN-IN FOR ALL 12 DAYS OF CAMP WILL RECEIVE THE “100 % BRUINS” T – SHIRT. THESE SHIRTS MAY NOT BE PURCHASED – NO EXCEPTIONS

Type of Payment

Check or Cash
Credit Card via Paypal

Varsity

Wins 3

Losses 6

Mail or Drop off:
Coach Jason Sport
1700 Hillcrest Drive
Bartlesville, Ok 74006