ELKS HOOP SHOOT Registration Form

Contestant’s Name*

First NameLast Name

Date of Birth*

Date

BoyGirl

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YesNo

If yes, how many prior years?

Preferred Parent Phone*

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Parent Email*

example@example.com

YesNo

If yes, please describe:

Below, please list the name(s) of the contestant’s parent(s) or guardian(s) who will accompany them to each Hoop Shoot contest or who should be contacted in case of an emergency.

Name*

First NameLast Name

Relationship*

Email*

example@example.com

Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Name*

First NameLast Name

Relationship*

Email*

example@example.com

Cell Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

As the parent and/or legal guardian of the contestant mentioned above, I request and permit their participation in the Elks Hoop Shoot Free Throw Contest. I assert that the information provided above is correct and accurate to the best of my knowledge. I may be asked to verify the contestant’s date of birth. If unable to provide proper verification, I understand the contestant may be disqualified. I understand that participation in the Elks Hoop Shoot is at the risk of the contestant and their family. I hereby release the Benevolent and Protective Order of Elks USA (BPOE) and the Elks National Foundation, Inc., from any claims, demands, liabilities, obligations, damages, costs, expenses, loss of service, and actions arising from any act or incident to the contestant’s participation or mine in connection therewith. I consent and authorize the BPOE and the Elks National Foundation, Inc., to use and reproduce the contestant’s name and/or likeness to circulate the same for any purposes reasonably related to the conduct and
promotion of the Elks Hoop Shoot contests.