Team Hines Wavier 1

Registration and Medical Release Form Parents/ Guardians please fill out
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I hereby grant permission and/or approval for the participation of my child
Name
Birth date

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip
Phone
Current grade
School
In the activities associated with Team Hines Basketball Academy, including practices, clinics, games, tournaments, field trips, and team social events. I agree not to hold Team Hines Basketball Academy, its officers and representatives, or the representatives of Team Hines Basketball Academy responsible for any injury that may result from participation in the program. I authorize the representatives of the Team Hines Basketball Academy to arrange for EMERGENCY MEDICAL TREATMENT ONLY for my child in the event that he/she should be injured or ill during the course of sports related activities, should I not be present. I agree to assume all costs associated with any such EMERGENCY treatment.
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Signature of Parent or Guardian

Clear
Print Name of Parent or Guardian
Print Full Name of Child
Family Physician
Phone
Address
Medical Insurance Carrier
Policy Number
Known Medical Conditions
In the event of an emergency please contact
Name
Phone (h)
TEAM HINES BASKETBALL ACADEMY
WAIVER OF LIABILITY
Childs Name
I approve of my child's participation in the Hines Basketball Academy program and hereby grant my permission for him/her to participate in activities of the program including participating in tryouts and in scrimmages against Team Hines teams. I will not hold Team Hines Basketball Academy. nor its officers, directors, team managers, administrators, or coaches liable for any injury that may occur during the conduct of its activities. I also understand that Hines Basketball Academy provides neither hospitalization nor any type of accident insurance for its participants.

Hines Basketball Academy., its officers, directors, administrators, managers, and coaches assume no liability for injury or damages arising and as a result of my child's participation in its basketball

Due to the strenuous nature of some activities, the participant is urged to consult his physician concerning fitness to participate. All activities present certain inherent risks and hazards, which the participant is urged to consider and which the participant assumes. In the event of an emergency, I hereby consent to emergency medical treatment for my child on my behalf. To the best of my knowledge, there are no physical or other conditions which will interfere with my child's participation.
ParentGuardian Signature

Clear
Date

MonthDayYear
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ParentGuardian Printed Name
Should be Empty:

TEAM HINES BASKETBALL ACADEMY

WAIVER OF LIABILITY