RegistrationThis form must be filled out and signed by a parent or guardian and mailed to Jessica Stevenson before participation in the camp will be allowed. Upon receiving the completed application form and payment, a confirmation email will be sent to the email address documented.

About Kamp Kooi: Kamp Kooi is a two day event July 28-29, 2014 from 8:00 to 11:00 am. at the Hinton Elementary School. Kamp Kooi is open to any student enrolled in the 3rd to 8th grades as of August 2014. Cost for the camp is $55.00.

Method of Payment(Checks payable to Jessica Stevenson)

5 Check 5 Cash

Camper Name: ______________________________________

School: ____________________________________________

Grade in Aug 2014: __________________________________

Address: ___________________________________________

City / State / Zip: ____________________________________

Cell Phone: _________________________________________

Home Phone: _______________________________________

Daytime Phone: _____________________________________

Email: _____________________________________________

T-shirt Size:5 Adult Small 5 Adult Medium 5 Adult Large 5 Adult X-Large

Emergency Contact Information

Name: ____________________________________________

Relationship: _______________________________________

Phone(s): __________________________________________

Jess

ica

Stev

enso

nAt

tn: K

amp

Kooi

315

Lake

shor

e Dr

North

Sio

ux C

ity, S

D 57

049Co

mpl

ete

both

sid

es o

f th

is f

orm

and

ret

urn

to k

amp

kooi

Health & ConsentThe following medical treatment form MUST be completed and SIGNED by the parent/guardian to enable the camper to participate.

As parent/guardian, I hereby authorize the camp staff at Kamp Kooi to act for me according to their best judgment in any emergency requiring medical attention, and I release the staff as well as the High Schools from any and all liability for injuries, illnesses, or lost property incurred while the below named camper is at camp. I understand the risks involved in participating in athletics, such as volleyball, which can include serious injury or death. I hereby grant permission for the above named camper to participate in the 2014 Kamp Kooi Volleyball Camp and if an injury should occur during, traveling to or returning from the camp, I agree to pay for all costs, present and future, through my medical insurance policy and/or personal finances. I have no knowledge of any physical condition that would be affected by the above named camper’s participation in the camp. I have attached any relevant medical information. Kamp Kooi retains the rights to use photographs of campers taken at camp for publicity and/or advertising purposes. By signing below, I consider this document to be legally binding.

Parent/Guardian Signature: ____________________________

Phone: ____________________________________________

Date: _____________________________________________

Medical: ___________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Mail to:Jessica StevensonAttn: Kamp Kooi315 Lakeshore DrNorth Sioux City, SD 57049

Com

plet

e bo

th s

ides

of

this

for

m a

nd r

etur

n to

kam

p ko

oi

2014 KampCamp will be held July 28-29, 2014 at the Hinton Elementary School from 8:00-11:00 am. Kamp Kooi is open to any student enrolled in grades 3-8 as of August 2014. This camp is designed to teach players the fundamentals of volleyball. Players will be drilled in all skill areas including setting, blocking, serving, attacking, and individual defense. In addition, team offensive and defensive systems will be incorporated.

Players will receive the best instruction from current and former collegiate volleyball players and coaches. In addition, all campers will receive a T-Shirt if form and payment are received by Wednesday, July 9.

For more information contact Jessica at:712.253.4493email: kampkooi@outlook.comfacebook.com/kampkooi