Building Bruins Youth Camp Registration

Name of Parent / Guardian *

First

Last

Parent/Guardian Phone *

Parent/Guardian Email Address *

Name Of Camper *

First

Last

Grade (2021-22 School Year) *

School *

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

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 member if 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

Second Parent / Guardian Name

First

Last

Family Physician *

Family Physician Address *

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Company

Insurance Policy Number

Photography Release *

I have read and give authorization
I have read and DO NOT give authorization

I, 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.

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