Private Lesson Request

Thank you for your interest in private lessons with FBKvolleyball! Once we receive your submission, we will reach out to you with information regarding the coach that you are matched with.

Each coach has varying availability as well as pricing (this will include a facility court fee). You can reach out to the coach that you are matched with to inquire about their personal pricing.

Athlete's Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade*

for school year 2025-2026

Team played on last season*

What skills do you want to target within your private lessons?*

Is there a specific coach that you would like to work with? If so, write their name here. If not, write N/A.*

Address*

Postal / Zip Code

Parent/Guardian Information

Name*

First NameLast Name

Cell 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 FBK VBC during the selected camp. In exchange for the acceptance of said child’s candidacy by FBK VBC, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless FBK VBC. 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 FBK VBC. 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 the FBK VBC. 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.

Facility Liablity Waiver

As Parent and/or Guardian of the named athlete, I hereby authorize I will not hold Gethsemane Church + Academy, its employees, or any other entities associated with Gethsemane Church + Academy responsible for any loss, damages, personal injury, infections, all contagious viruses, exposure to communicable diseases, disability, and death as a result of participation in all training, practices, games, classes, programs, camps, clinics or private lessons.

The terms hereof shall serve as a release and assumption of risk for my heirs, estate, executor, administrator, assignees, and for all members of my family.

I hereby authorize Gethsemane Church + Academy and/or the appropriate staff to act for my child according to their best judgment in an emergency requiring medical attention.

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*

Date

Signature*

Private Lesson Request

Athlete Information