Henrico PAL - Johnny Newman Basketball Camp Registration

Child's First Name

Child's Last Name

Gender

Birthday

Age

Height

Weight

Parent/Guardian’s Name

Address Line 1

Address Line 2

City

State

Postal Code

Email Address

Phone Number

(Example: 8005551212)

Emergency Contact

Emergency Phone

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Current Henrico County Resident

School Entering Fall 2010

Grade Entering Fall of 2010

Select the highest-grade level of basketball that you have played

Did your child attend camp last season?

Counselor

T-Shirt Size

Insurance Provider

Policy Number

Continue to Step 3

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REGULATIONS:
To be eligible to participate in summer camp activities, a participant and his/her parent or guardian must completely fill out and properly sign this form attesting that the participant is physically fit for athletic competition and that the parent or guardian consents to such participation. A physical medical examination, while not compulsory, is highly recommended prior to participating in any Henrico PAL sponsored recreational/sport program. Accident insurance is recommended for all participants in any Henrico PAL sponsored recreational/sport program and it is the responsibility of the parent/guardian to provide such insurance.

PARTICIPATION CONTRACT: 
We hereby verify that the above information is true and correct, and that (participant's name) _________________________________ is physically fit for Camp. We understand that any false information will result in the loss of summer privileges and immediate suspension from the summer camp noted below for the remainder of the summer camp. The participant agrees to comply with the rules and regulations for the recreational/sport, recreational facilities and activities as established by the Henrico Police Athletic League no refunds will be granted. If total payment is not received by 5/3/10 the child will be dropped from the summer program and PAL will retain the deposit. All changes must be made prior to 5/3/10.

PARENTAL CONSENT AND WAIVER:
I hereby consent to and approve of the above named child participating in the Henrico PAL Summer Camp. I understand the risks associated with participating in this camp and hereby waive, for myself and the above named child, any and all claims, demands and right of action against the County of Henrico, and the Henrico Police Athletic League employees, coaches and officials of the league for any injury or accident which may occur to the said child as a result of participating in this camp.  The parent(s) and/or guardian(s) consent to and understand that photographs and/or images captured during the summer camp may be utilized in Henrico PAL literature and advertisement.

WAIVER
In consideration of my child being allowed to participate in, or assist with, the Henrico PAL/Johnny Newman’s 4th Annual Basketball Camp, and on behalf of myself, my child, my children, and my successors, heirs, representatives, executive and/or assigns (collectively referred to as “releasing parties”, I release and forever discharge Henrico PAL, Johnny Newman, The Newman Group, Johnny Newman School of Basketball, agree not to sue the National Basketball Association, The County of Henrico and their respective owners, directors, shareholders, officers, partners, affiliates, representatives, limited partners, general partners, parents, agents, and employees (collectively “the released parties”) from any and all liability claims, liens, actions, or causes of action of any nature whatsoever arising out of any damages, losses, or injuries (including death) to the releasing parties and/or their property while participating in the Henrico PAL/Johnny Newman 4th Annual Basketball Camp on 8/16-19/09 at Highland Springs High School or any other activities which may be contemplated and conduction at such School of Basketball on such dates regardless of the cause(s) of such loss, injury, (including death) or damage. I know the risks and dangers inherent in participation in the School of Basketball. As further consideration of my child being allowed to participate in the School of Basketball described herein, the undersigned agrees, jointly and severally, to defend, indemnify, and hold harmless the released parties from and against and in any respect of liabilities, claims, liens, actions, causes of action, cost or expenses of any nature whatsoever (including, without litigation, interest, penalties, reasonable attorneys’ fees and disbursements) arising from any damage, loss, or injury (including death) to the releasing parties resulting from the School of Basketball described herein regardless of the cause or causes of such damage, loss, or injury (including death). My child or children voluntarily assume all risks of injury to his/her/their person (including death) and his/her/their property that may be sustained by participating in the Henrico PAL/Johnny Newman’s 4th Annual Basketball Camp. I certify that my child is in good mental and physical condition. I herein by acknowledge that I have carefully read this Liability Waiver/Release Form and fully understand its content.

By entering my initials, I herein by acknowledge that I have carefully read this Liability Waiver/Release Form and fully understand its content.

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