2008 Hoops Camp

Medical Release Form

Family Doctor:_____________________________

Phone: ___________________________________

List any physical or mental problems, including allergies:

___________________________________________________________

___________________________________________________________

In case of accident or sudden illness (in the event I cannot be reached by phone), I hereby authorize Green Acres Baptist Church and/or Robert E. Lee High School to refer this child to the above named physician and/or to the emergency room at:

Trinity Mother Frances    ____  

East Texas Medical Center    ____     
     (please check only one)

I hereby waive any and all claims or rights of action against Green Acres Baptist Church and Robert E. Lee for damages and/or injuries sustained by my child/children while participating in Camp.  I also give my permission for photos of my child to be used for future promotions.

Signature of Parent

__________________________________________________________

Today's Date ___________ / ___________ / __________

Mail registration Form, Medical Release, and Payment to:

Green Acres Baptist Church
Attn: Recreation Ministry
1607 Troup Hwy
tyler, TX  75701

OR