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Register for Shane Roller's Intensive and Technique Camp

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-- Account Information -- Please note your email used and password.
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The deposit amount must be paid at the time of registration. You may pay more than the minimum deposit or pay the full amount due. ALL MUST BE PAID UPON ARRIVAL TO THE CAMP. PLEASE NOTE THAT YOUR DEPOSIT IS NON-REFUNDABLE.

PERMISSION FOR MEDICAL TREATMENT, RELEASE OF MEDICAL INFORMATION AND PAYMENT OF MEDICAL EXPENSE: I REQUEST AND GIVE PERMISSION to physicians and medical staff to treat the above-named participant appropriately, including hospitalization, prescribing medication, and performing emergency medical procedures. I AUTHORIZE release of any medical information to the medical centers which may be pertinent to any diagnosis or treatment of the above-named participant. I UNDERSTAND that any charges resulting from this medical treatment will be billed to me at my address or to my medical insurance carrier. Waiver: My son/daughter has been examined by a physician in the last year and is in good health. I hereby authorize the Shane Roller All Star Camp Staff to act for me, according to its best judgement in any medical emergency, and I hereby waive and release said camp from any liability for injuries or illness incurred by my son/daughter while attending camp.
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Payment Info
 
Deposit Amount: (minimum $100.00)     Credit Card Number:




Log in to make payments after registering

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