Basketball Camp Registration Step 1 of 5 20% Camp SelectionCamp Selection*Jays Kids Camp – $75Camp 2 – $295Camp 3 – $295If the camp you are interested in is closed, you can email Christopher Jennings at jennings@jesuitnola.org to be placed on a waiting list.Total $0.00 Camper InformationName* First Last NicknameIf the student has a preferred name or a nickname, please indicate it here.T-Shirt Size*Youth SYouth MAdult SAdult MAdult LAdult XLDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School*The school that the student attends as of May this yearGrade*Student's grade in August of this year Parent/Guardian InformationParent/Guardian 1* First Last Email* Cell Phone*Daytime PhoneEvening PhoneParent/Guardian 2 First Last Email Cell PhoneDaytime PhoneEvening PhoneHow did you hear about Jesuit Blue Jay Basketball Camp?* Other campers Jesuit's web site Email from Jesuit Relative or friend attends/attended Jesuit Advertisement Medical Insurance CoverageEmergency / Medical Information - Please list your camper’s medications or any medical issues. If he has medication, please inform us here and in person when arriving on the first day of camp.Name of Medical Insurance Provider*Provider's Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Policy Holder's Name*Policy/Group Number*Family Physician*Physician's Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician's Phone* Consent for Camp ActivityParental Consent - I hereby give permission for my child to participate in the Jesuit Blue Jay Basketball Camp. If injured during camp activities. Should the family physician and we not be available, the Jesuit Basketball Camp instructors are authorized to send our son to a physician or hospital of their choice. By typing my name below, I agree to the terms stated above.*Photo Release - I grant permission for Jesuit High School of New Orleans (Jesuit) to photograph or film my child’s name, image, likeness, spoken words, student work, and performance with or without associating names thereto and in any form (hereinafter collectively referred to as “Works”), and to use, publish, display, distribute, produce, duplicate, sell, and copyright these Works in connection with any promotional material that may be created by Jesuit High School. I waive any claim for compensation of any kind for the School’s use or publication of the Works of my son. I hereby release, discharge, and agree to hold harmless Jesuit and those acting under its authority from any liability to the extent provided by the law, for use or publication of the Works described above. By typing my name below, I agree to the terms stated above.* PaymentTotal $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Billing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CAPTCHAPlease click "Submit" only once. Clicking more than once will process the registration and payment multiple times.