Registration

This form must be flled 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 confrmation 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): __________________________________________
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Health & Consent
The 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 fnances. I have no knowledge of any physical
condition that would be affected by the above named campers
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 Stevenson
Attn: Kamp Kooi
315 Lakeshore Dr
North Sioux City, SD 57049
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2014 Kamp
Camp 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:
712.253.4493
email: kampkooi@outlook.com
facebook.com/kampkooi