Shadow Mountain Community Church - Sports - Basketball Camp Registration

Sports - Basketball Camp Registration

Participant Information
First Name	*
Last Name	*
Grade for 1016/17	*
Gender	*
Shirt Size	*
Parent/Guardian Information
First Name	*
Last Name	*
Phone	*
Your Email Address	*
Liability Release
THIS IS AN ACKNOWLEDGEMENT OF RISK, ASSUMPTION OF LIABILITY, WAIVER, RELEASE AND INDEMNIFICATION.
I and/or my minor child have asked to participate in Sports @ Shadow Mountain, a Ministry of Shadow Mountain Community Church. I understand that no activity or program is absolutely safe and free of risk. I agree to assume full responsibility for myself or my minor child. I expressly assume all risk and responsibility involving all accidents or injuries sustained while participating in the above-stated activity. I further assume full responsibility for any damages to persons and/or property resulting from any negligence on my part or on the part of my minor child.
I affirm that I and/or my minor child are fully capable of participating in this activity and that my general health is good. I do not have any condition that might endanger the life or health of myself or others participating or attending the performance or any other activity. I affirm that I know of no reason why I and/or my minor child should not participate.
I, on behalf of myself, my child, my assigns and my estate, do voluntarily agree to release and hold harmless Shadow Mountain Community Church, its officers, board members, agents, volunteers and employees for any and all claims for injuries, causes of action or liability related to my participation in any and all activities before, during and after the event.
Should Shadow Mountain Community Church, or anyone acting on it’s behalf, be required to incur any attorney’s fees and/or costs to enforce this agreement, I agree to indemnify and hold Shadow Mountain Community Church harmless for all such fees and costs.
By signing this document, I acknowledge that if anyone is hurt or property damaged during my participation in this event, I and/or my minor child may be found by a court of law to have waived any right to maintain any lawsuit against Shadow Mountain Community Church on the basis of any claim which has been released herein. I have had sufficient opportunity to read this entire document. I have read and understood it and I agree to be bound by its terms.
This liability release shall be legally binding upon heirs, assigns, legal guardians, representatives and my self. Again, I have carefully read this agreement and understand its contents. I am aware that I am releasing certain rights that I otherwise may have and I enter into this agreement on behalf of myself and/or my minor child of my own free will.
For a MINOR CHILD, (under 18 years of age) please fill out the information below and sign:
As parent/legal guardian of (child’s full name)	*
I further accept responsibility for the actions of this child and agree to the provisions of the above. (Parent’s full name)	*
Signature	*
Dated	*
THIS IS AN ACKNOWLEDGEMENT OF RISK, ASSUMPTION OF LIABILITY, WAIVER, RELEASE AND INDEMNIFICATION.
Consent to Treatment
Participant’s First Name	*
Participant’s Last Name	*
Emergency Contact Information - #1
First and Last Name	*
Phone 1	*
Phone 2
Emergency Contact Information - #2
First and Last Name	*
Phone 1	*
Phone 2
In the event of injury, illness or any other circumstances that may require medical attention, I hereby give my consent for any treatment deemed necessary by staff, volunteers or any medical professional and I further agree to pay for any and all expenses connected with this medical treatment. This consent to treatment shall remain if effect for one year from the date of my signature.
*If you do not have Health insurance you are not permitted to participate
Health Insurance Carrier Name	*
Policy / Record #	*
Doctor’s Name	*
Doctor’s Phone Number	*
Participant has the following allergies and/or medical conditions
Participant is taking the following medications
Signature	*
Date	*
If participant is a minor continue here
Parent/Legal Guardian	*
Phone 1	*
I certify that (child’s full name)	*
is physically able to participate in all sports activities except:
Signature	*
Dated	*

Total	$