Medaille College Basketball Clinic - Register Now

Medaille College Martin Luther King, Jr. Day Basketball Clinic Registration

Cost: $25

Please fill in all blanks completely. Questions? Call (716) 880-2357

In case of emergency, contact
Primary physician’s name & phone number

*Make checks payable to Medaille Basketball. Mail to Medaille College, 18 Agassiz Circle, Attn: Rachelle Matthys/Athletics, Buffalo, NY 14214

Basketball Camp Health Form

Home Address
If NOT available in an EMERGENCY, please notify:
(Check and give approximate dates if applicable only)
Ear Infection Dates
Rheumatic Fever Dates
Convulsions Dates
Diabetes Dates
Loss of Paired Organ Dates
Epilepsy Dates
Glasses/Contacts Dates
Hearing Impairment Dates
(Check applicable)
(Check applicable and give approximate dates)
Chicken Pox Dates
Asthma Dates
Cancer/Leukemia Dates
Any Specific Activities to be:
Due to New York State Health Department regulations, we need dates of immunizations against the following:

IMPORTANT: Please notify the camp if the camper has been exposed to any communicable diseases during the three weeks PRIOR to camp attendance.

Health Insurance Information



This Health History is correct as far as I know and the person herein described has permission to engage in all prescribed activities, except as noted by me.

please type full name

In the event I cannot be reached in an EMERGENCY I herby give permission to the physician selected by the camp director to secure proper treatment for my child as named above.

please type full name

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Undergraduate Programs

High school students and transfer students who want to enroll in day classes at the Buffalo campus.

Adult and Graduate Programs

Adult learners applying to our undergraduate or graduate degree programs at either our Buffalo or Rochester campuses.

Online Programs

Adult learners applying to our online undergraduate or graduate degree programs.