Name: _____________________________________________________

Home Address: ______________________________________________

City: _______________________________ State: __________________

Zip code :____________ _ Date of Birth: ____________

Graduation Year: ____________ Email: ___________________________

School District: _____________________________________________

Primary Phone:______________________________________________

Primary Care Physician: _______________________________________

Office Phone Number: ________________________________________

Is camper currently being treated by a physician for injury or illness?

If yes, explain:_______________________________________________

List Medical Conditions:________________________________________

List medications currently taken:_________________________________

List allergies: ________________________________________________

Policy Holder’s Name: ________________________________________

Address: __________________________________________________

City/State/Zip:_______________________________________________

Primary Phone:______________________________________________

Plan #: ___________________________________________________

Group #:__________________________________________________

Policy #___________________________________________________

Contact #:_________________________________________________

Relationship to Camper: ______________________________________

Emergency #: _______________________________________

As the parent/guardian of the camper listed above I hereby agree to the following as a

condition of ____________________________’s participation in the GVSU summer camp

program and related services.

I give my permission to GVSU, St. Mary’s Hospital, Spectrum Health Care System, North

Ottawa Community Hospital, Metropolitan Health Care System or other health care provid-

ers to provide, seek, obtain, or approve any routine, necessary, or emergency health care

during the camper’s involvement in the GVSU summer camp program. I understand that this

authorization is given in advance of any specific diagnosis, or treatment or medical care being

required and is to serve as specific consent to any and all such diagnosis, treatment or

hospital care which may be deemed advisable. I understand my rights under the Health

Insurance Portability and Accountability Act (HIPPA) and authorize GVSU to release infor-

mation as necessary for managing summer camp health care.

I attest that a physician has examined the camper in the past twelve months and he/she was

found to be in good health. I attest that currently there is no medical reason for the camper

not to participate in the strenuous physical activities of the sports camp program.

I acknowledge that participation in sports camp and related activities involves assumed and

inherent risk of personal injury. I assume such risk on behalf of the camper and give my

permission to the camper to participate in all sports camp activities. I release and agree to

hold harmless GVSU, its Board of Trustees, students and employees from all claims, actions,

damages, and liabilities for personal injury or damage relating to or arising out of any sports

camp activity except where the injury or damage is caused by the gross negligence of the

university’s employees. I understand that the camper will be subject to the rules and regula-

tions of the GVSU sports camp. I understand that any person who repeatedly disobeys camp

policies or procedures will be immediately expelled from camp. GVSU is not responsible for

lost or stolen property.

___________________________________________________________________

Signature of Parent or Guardian Date Gran

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June 25th

Play like a

LAKER!

R E G I S T R A T I O N

I N F O R M A T I O N

Elite Camp - $100

Payment and Registration

These camps fill up fast, all applicants accepted on a

first come first serve basis. Camp numbers will be

limited to ensure individual attention.

Method of Payment (U.S. Funds Only)

You may complete the registration medical form on

this brochure and mail to the address listed below. If

paying by check, please send with your registration.

You may also mail in your registration and pay by

credit card. The final option to register is to do so

online. Once we have your registration, we will send

you confirmation via EMAIL with instructions and

logistics of the camp.

If you have any questions, please feel free to contact

us at (616) 331 - 3526 or burgesja@gvsu.edu

Register with brochure:

□ Checks payable to: Grand Valley State University

□ To pay by credit card, please call Janine Warfield

at (616)331-2330

Register completely online at:

http://www.grandvalleystatewbbcamps.com/

If registering by this brochure, Please mail to:

GVSU Women’s Basketball

1 Campus Dr., 163 FH

Allendale, MI 49401

Refund Policy

A $50 non-refundable deposit will be required with regis-

tration. Students leaving the camp will not receive a refund

unless they are forced to leave early for medical reasons.

Janel Burgess-Head Coach Janel Burgess enters her eighth season as the women's basketball

coach at Grand Valley State. Burgess is 117-76 in her seven-year

GVSU career. During her first two seasons, she tallied 36 victo-

ries, which is the most for any Laker coach in their inaugural two

years at GVSU. Her .606 winning

percentage ranks fourth in program

history. GVSU is excited about the

2013-2014 season and graduates only

two seniors. GVSU has been excep-

tional defensively and is increasing

their scoring efficiency again this

season. With a strong recruiting class

coming to GVSU combined with

experienced returnees, the Lakers

look forward to continued success for

years to come. Janel, a native of Mil-

lersburg, Iowa, resides in Allendale

with husband, Tim, and their children,

Eddie (11) and Sydnee (5).

“Grand Valley State University is an amazing university. We pursue championships in all we do. Come join us for a high in-tensity day of Laker Basketball. You will be immersed in the academic expectations, strength and conditioning techniques, and basketball philosophy that we use on a daily basis. If you have the desire to play college basketball, this will be an invalua-ble experience for you.” -Coach Burgess

Briauna Taylor & Alex Stelfox

~ most recent 1000+ point Laker Scorers

Recommended ages 8th-12th Grade

Registration is from 8:30 - 8:50 am

Camp Session: 9:00 am –9:00pm

The Elite Camp will focus on all the fundamentals

needed to perform at the college level. The camp will

be a high energy, high intensity and a look at what it

takes to be a Laker. The Coaching Staff and players

will guide you through drills, competitions and even

strength and conditioning techniques that will help take

you to the next level. There will be plenty of Laker

interaction allowing you to really get to know the Lak-

ers both on, and off the court. Even a look into the

academic side of both preparing for and succeeding in

college athletics. If you’re a female student-athlete

that wants to play at the next level, this is the camp for

you.

If you have any questions about the camp or the re-

cruiting process, please contact: Head Coach Janel

Burgess: burgesja@gvsu.edu

Elite Camp June 25, 2015

Register online at http://www.grandvalleystatewbbcamps.com/