Duncan Hoops Clinic Registration Form

DUNCAN HOOPS REGISTRATION

CLINIC REGISTRATION AND PAYMENT FORM
ATHLETE INFORMATION
Athlete's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENT/GUARDIAN INFORMATION
Name*

First NameLast Name
Primary Phone Number*
E-mail*
example@example.com
EMERGENCY INFORMATION
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the athlete prescribed an inhaler? If yes, please explain any instructions.
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Duncan Hoops during the selected camp. In exchange for the acceptance of said child’s candidacy by Duncan Hoops, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Duncan Hoops. and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against Duncan Hoops. including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to Duncan Hoops and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Media Release Form - Photographs and/or Video As Parent and/or Guardian of the named athlete, I am fully aware that the athlete's likeness may appear on social media platforms and promotional materials. I further grant Duncan Hoops the
irrevocable and unrestricted right and permission to copy/reproduce and distribute my athlete's Likeness by means of various media, including, but not limited to video presentations, news releases, mail-outs, emails, brochures, placement on websites and/or other electronic/digital delivery, social media, publication, display, or promotions on any and all other media, and I further understand that My Likeness may be subject to reasonable modification or editing. I hereby waive any right to inspect or approve the finished images or other content, including advertising copy or printed matter, in which they may be used.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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DUNCAN HOOPS REGISTRATION