PARTICIPANT INFORMATION

FIRST NAME:

LAST NAME:

School You Attend:
Grade Level:
Gender: Male   Female
T-Shirt Size: Small    Medium  Large 1X  2X

Age:

Date of Birth (mm/dd/yyyy):
How did you hear about our camp/clinics:

TRAINING - CAMPS & CLINICS

Which are you registering for:

EMERGENCY CONTACT

Parent /Guardian Name (Required)
E-mail (Required)
E-mail (Second)
Street Address
Address (cont.)
City   State/Province Zip/Postal Code
Primary Phone #1 Cell Home Office
Alternative Phone #2 Cell Home Office
Fax
   

MEDICAL INFORMATION (All Information you provide is confidential)

Medical Insurance Company:
Medical Insurance Number:
Medical Notes:

Known Allergies, Physical Restrictions, Mental Restrictions, etc.

 

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

IN CONSIDERATION of the listed registrant's being accepted for the 2010-11 Virginia Elite Basketball Skills Academy programs and activities (the "Programs"), I, for myself and the registrant, for which I am parent and/or legal guardian, and my assigns, heirs, and next of kin:

1. ACKNOWLEDGE, agree and represent that my son/daughter (the "registrants") has received a physical examination by a physician and has been found to be capable of participating in the Programs. I hereby give my consent to have an athletic trainer and/or doctor of medicine or dentistry provide my son/daughter with the medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of each assistance and/or treatment.

2. FULLY UNDERSTAND that: (a) basketball involves risks and dangers of serious bodily injury, including permanent disability, paralysis, and death ("Risks"); (b) these Risks and dangers may be caused by my registrant's actions or inactions, the actions or inactions of others participating in the Programs, the condition in which the Program takes place, or the negligence of the "Releases" named below; and (c) there may be other risks and social economic losses either not known to me or not readily foreseeable at the time. I hereby accept and assume all such risks and all responsibility for losses, costs, and damages incurred as a result of my registrant's participation in the Programs.

3. HEREBY RELEASE, discharge and covenant not sue Virginia Elite, coaches, players, trainers or personnel involved in sponsoring the Programs, the managers of the Programs and their respective affiliates and all of their respective administrators, directors, agents, officers, members, volunteers and employees, other participants, any sponsors, advertisers, and if applicable, owners and lessors of premises on which the Programs take place (each considered one of the "Releases" herein) from any and all liability, claims, demands, losses, or damages on my or the registrant's account caused or alleged to be caused in whole or in part by the negligence of the "Releases" or otherwise, including negligent rescue or operations; and I further agree that if, despite this Release and Waiver of Liability, Assumption of Risk and Indemnity Agreement, or anyone on my or the registrant's behalf, makes a claim against any of the "Releases," I will defend, indemnify, save and hold harmless each of the "Releases," from any and all litigation expenses, attorney fees, losses, liabilities, damages, or costs which may incur as a result of such claim.

4. HEREBY GRANT Virginia Elite the right to use images of my son/daughter in the future marketing and/or promotion of the Programs, or Virginia Elite generally through the use of his or her image or likeness in all promotional materials and internet initiatives, including flyers, brochures, and online.

I have read this agreement, fully understand its terms, understand that I have given up substantial rights by signing it and have signed it freely and without inducement or assurance of any nature and intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid the balance notwithstanding, shall continue in full force and effect.

Parent /Guardian Name (Required): 

Date of Birth (mm/dd/yyyy) (Required):

PAYMENT INFORMATION 

Did You Pay  Online

No    Yes 

VIRGINIA ELITE SPRING BREAK CAMP REGISTRATION FORM