Gideon T. Johnson Sr.

Football Camp
Registration Form
P.O. Box 144
Jacksonville, N.C. 28541
Name:________________(first)__________________(middle)________________(last)
Birth Date:__________________ Age:__________
Years of Football experience:_________ what position(if applies)__________________
Home Address:___________________________________________________________
City:_______________________________ State:____________ Zip:_______________
E-mail(optional):_________________________________________________________
May we share your e-mail address with local football camps only? Yes__ No__
Name of Parent(s):________________________________________________________
*I do or do not give the GTJ SR. camp permission to photograph my child(ren) during this
event. (please circle one)
What do you want your child to gain from this experience?
______________________________________________________________________________
_______________________________________________________
Shirt Size: (check one) Youth M___ L___XL____ Adult S____ M____L______XL____
XXL__
CAMP GOAL: Emphasis placed on explaining the term student-athlete, understanding moral
values, and learning basic football skills June 13-15, 2016 (530pm to 830pm) Jacksonville High
School
* There will be no equipment used during the Gideon T. Johnson Sr. Football Camp,
however, staff cant prevent accidental injury. There will be no physical contact during the
Gideon T. Johnson Sr. Football Camp.* GRADES (k-8)
Insurance information:_____________________________________________________
Medical Concerns:__________________________________________________________
Emergency Contact(name & number):________________________________________
Secondary Emergency Contact:_____________________________________________
RELEASE AND WAIVER OF CLAIMS
My child(ren) has permission to attend the Gideon T. Johnson Sr. Football Camp. Enclosed is a
$20.00 non-refundable fee. Applications at check-in are accepted space permitting. I have no
knowledge that my child(ren) has physical limitations that may cause concerns. It is my
understanding that by signing this form I am releasing all individuals providing instructions and
hosting the Gideon T. Johnson Sr. Football Camp from any legal actions.
Contacts: Kendrick Rogers (910) 340-3528 or G.T. Johnson Jr. (910) 358-2644

Signature (Parent or Guardian)

Date