2022 Boys or Girls Basketball Camp with Coach Spears

Space is no longer available in the Boys Camp (6-15 year olds) or the Girls Camp (9-15 year olds).

Parent's/Guardian's Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Main Contact Phone *

Area Code Phone Number

Main Email *

Registration is $165/participant. Additional children of the immediate family will receive $10 off for the first sibling and $5 off for each sibling after that. This discount does not apply to the Little Hoopsters Camp.

Number of children, who are participating in Boys and/or Girls Camps *

1 child 2 children 3 children 4 children

Child's Name (#1) *

First Name Last Name

Camp (Select one - Space is no longer available in the Boys Camp, ages 6-15, or the Girls Camp age group 9-15) *

Girls Camp (6-8 year olds) - July 11th-July 15th

Date of Birth *

Age *

Shirt Size *

Medical Conditions (Please List) *

Child's Name (#2) *

First Name Last Name

Camp (Select one - Space is no longer available in the Boys Camp, ages 6-15, or the Girls Camp age group 9-15) *

Girls Camp (6-8 year olds) - July 11th-July 15th

Date of Birth *

Age *

Shirt Size *

Medical Conditions (Please List) *

Child's Name (#3) *

First Name Last Name

Camp (Select one - Space is no longer available in the Boys Camp, ages 6-15, or the Girls Camp age group 9-15) *

Girls Camp (6-8 year olds) - July 11th-July 15th

Date of Birth *

Age *

Shirt Size *

Medical Conditions (Please List) *

Child's Name (#4) *

First Name Last Name

Camp (Select one - Space is no longer available in the Boys Camp, ages 6-15, or the Girls Camp age group 9-15) *

Girls Camp (6-8 year olds) - July 11th-July 15th

Date of Birth *

Age *

Shirt Size *

Medical Conditions (Please List) *

Alternative Emergency Contact

First Name Last Name

Relationship

Phone Number

Area Code Phone Number

Family Medical Insurance:

Carrier

Group #

Policy #

Family Physician *

Phone *

ACKNOWLEDGEMENT OF WARNING AND ASSUMPTION OF PERSONAL RESPONSIBILITY ** Each registrant’s parent or guardian must agree to this statement.In consideration of the athlete, who is listed on this registration form, being allowed to participate in any ACTSports related events and activities, undersigned acknowledges, appreciates, and agrees that: The risk of injury to my child from the activities involved in these programs is significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 1) For myself, spouse and child, I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releasees or others, and assume full responsibility for my child's participation; and, 2) I willingly agree to comply with the program's stated and customary terms and conditions for participation. 3) I myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, hereby release and hold harmless ACTSports, its directors, officers, officials, agents, employees, volunteers, other participants, Victory Worship Center and World Outreach, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event ("Releasees"), with respect to any and all injury, disability, death, or loss or damage to person or property incident to my child's involvement or participation in these programs, whether arising from the negligence of the releasees or otherwise, to the fullest extent permitted by law. 4) I realize that there will not always be trained medical personnel on-site at the program’s practices, games, and activities/events.

ACKNOWLEDGEMENT OF COVID-19 LIABILITY WAIVER**
I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.

I further acknowledge that ACTSports, Inc. has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that ACTSports, Inc. cannot guarantee that I, my player, and other family members will not become infected with the Coronavirus/Covid-19.

I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, ACTSports staff, and other players and their families.

I voluntarily seek services provided by ACTSports, Inc. and acknowledge that I am increasing my and my player's risk of exposure to the Coronavirus/COVID-19. I acknowledge that I and my player must comply with all set procedures to reduce the spread while participating in ACTSports activities.

I attest that:

* I and my player(s) are not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.

* I and my player (s) have not traveled internationally within the last 14 days.

* I and my player(s) have not traveled to a highly impacted area within the United States of America in the last 14 days.

* I do not believe I or my player(s) have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.

* I and my player(s) have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.

* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.

I understand that if any of the above circumstances change during the season, I will notify the ACTSports Director immediately. I also understand that anyone who has tested positive with Coronavirus/COVID-19 will not be permitted to attend ACTSports events until they have been released by their doctor and diagnosed as clinically recovered.

FIRST AID AND EMERGENCY MEDICAL TREATMENT: I/we hereby grant consent to any and all health care providers designated by ACTSports to provide my child (registered ACTSports athlete) any necessary medical care as a result of any injury/illness. This consent includes First Aid, CPR, and transportation to/from health care providers. In case of emergency, and if emergency transportation is needed, I agree to pay all costs of medical care and transportation.

RELEASE TO USE IMAGE AND LIKENESS: On occasion, ACTSports or its representatives take photographs or make audio or videotape recordings of children and/or adults involved in activities. Such photographs or video records may be used by staff and participants to remember the activities and participants. Local news organizations may hear of our activities or events, and our organization may invite or allow them to photograph or record our events for news reporting on special interest features. I consent to the use of any such audio or visual record of the child named above to be used, distributed, or displayed as agents of the organization see fit. This consent includes but is not limited to: photographs, videotape, and audio recordings. Furthermore, I give permission for the child to be interviewed by the news media, or for such photographs and other audio or visual records to be used by the news media. In addition, such photographs and audio/visual recordings may be used in publications or advertising materials to let others know about our activities and to promote the ministry of ACTSports.

I accept *

Acknowledgement of Warning and Assumption of Personal Responsibility Acknowledgement of COVID-19 Liability Waiver First Aid and Medical Treatment

Release to Use Image and Likeness (Check One) *

Yes, I accept the "Release to Use Image and Likeness" No, I do not accept the "Release to Use Image and Likeness"

Registration *

1 Registration $ 165.00

2 Registrations $ 320.00

3 Registrations $ 480.00

4 Registrations $ 640.00

Boys or Girls Basketball Camp with Coach Spears

Parent/Guardian Information

Participant Information

Alternative Emergency Contact

Insurance/Assumption of Risk/Emerg. Medical Treatment/Parental Code of Conduct/Image Release