Registration Name* First Last Email* Enter Email Confirm Email Gender* Male Female Grade* 9th 10th 11th 12th Shirt Size* Small Medium Large XL XXL Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Have you attended the game camp in the past?* Yes No, this is my first time. Medical InformationMedical Release*By typing my name as electronic signature above, I grant permission for my dependent child to be treated medically while in attendance at Southern Arkansas University. I further authorize treatment at Magnolia Hospital of Magnolia, Arkansas, by physicians in attendance at that facility should treatment be required beyond the capabilities of the university physicians.Are there any allergies or special disability of which we should be aware?Are there any special medications or treatments your child takes?Is your child covered by any form of hospitalization or surgical insurance? If yes, provide the name of the company and the policy number below. Yes No Name of Insurance Company and Policy Number:Emergency Contact InformationName* First Last Relationship to Student*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhonePhoto Release StatementBy submitting this application, I and my legal guardians hereby give express written permission for my photograph to be used in the advertising and promotion of Southern Arkansas University. This includes printed as well as electronic publications. Would you like to pay now online or pay via check/mail?* Pay via check/mail Pay online via credit card This field is hidden when viewing the formPaymentRegistration Fee Price: Credit Card DiscoverMasterCardVisaSupported Credit Cards: Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name Total $0.00 This field is hidden when viewing the formTransaction IDThis field is hidden when viewing the formDateThis field is hidden when viewing the formCodeThis field is hidden when viewing the formDescription Δ
