Building Bruins Youth Camp Registration Please enable JavaScript in your browser to complete this form.About You, The Parent / Guardian - Step 1 of 4Name of Parent / Guardian *FirstLastParent/Guardian Phone *Parent/Guardian Email Address *Name Of Camper *FirstLastGrade (2021-22 School Year) *1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th GradeSchool *Central Middle SchoolMadison Middle SchoolHoover ElementaryJane Phillips ElementaryRanch Heights ElementaryRichard Kane ElementaryWayside ElementaryWilson ElementaryNot ListedEnter School Name If not ListedHome Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextDisclaimer / 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 member if necessary, and I agree to pay either directly or through my own personal health and accident insurance policy all medical costsEnter First and Last Name as Signature for acceptance of Dislaimer / Policy Statement *Date of acceptance for Disclaimer / Policy Statement *Street Address of Signing Parent / GuardianAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextParent / Guardian Name *FirstLastSecond Parent / Guardian Name FirstLastFamily Physician *Family Physician Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeInsurance CompanyInsurance Policy NumberPhotography Release *I have read and give authorizationI have read and DO NOT give authorizationI, the parent or legal guardian, do hereby grant permission to the program and its employees or representatives, to take and use: photographs, video and/or digital images of my child for the use in promotional or educational materials pertinent to the program as follows: Printed publications or materials ; In electronic publications or presentations ; On the Bartlesville website. I agree that my child's identity may be revealed in descriptive text or commentary in connection with the image(s). I authorize the use of these images indefinitely without compensation. NextType of PaymentCheck or CashCredit Card via Paypal Mail or Drop off: Coach Jason Sport 1700 Hillcrest Drive Bartlesville, Ok 74006 PayPal screen will prompt after select SUBMIT CommentSubmit