Name ________________________________    Address__________________________________

City __________________________     Phone ___________________    Birthdate_____________

School ___________________________________        Grade ('08– '09 school year)__________

In Case of Emergency Contact: _____________________________ Phone _________________

Parent’s/Guardian’s Signature:______________________________________________________

Circle T-Shirt Size

 (adult)  small       medium         large        x-large            (youth)   large      medium 

CONSENT AND WAIVER

I hereby agree on behalf of the named student and her parent or legal guardian, to waive
any claims for liablility against the school, the Diocese of Harrisburg (and any Diocesan
or school officials, agents or employees) which may arise from the participation of the
named student in the Lebanon Catholic Girls Basketball Camp.

__________________________________
(Print Parent's Name)

__________________________________
(Parent's Signature)

__________________________________
Date