BMG Power of Her All Girls Clinic Registration Form

BMG Power of Her All Girls Clinic Registration

Wednesday July 9th 2025
Clinic Time 9am or 1 pm
Athlete Information
Athlete's Name

First NameLast Name
Birth Date

MonthDayYear
MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number

Area CodePhone Number
MobileNumber
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 Basketball Mount Gambier Inc during the selected camp. In exchange for the acceptance of said child’s candidacy by Basketball Mount Gambier, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Basketball Mount Gambier Inc. 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 Basketball Mount Gambier Inc . 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.
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.
Date

MonthDayYear
Date
Signature

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BMG Power of Her All Girls Clinic Registration

Athlete Information