Got Game? Get Game! Youth Basketball 4th Season Age Groups 6 - 14
Name______Age______Current Grade______
Parent’s Name______
Phone (H) ______(C) ______
Email ______
Doctor Name, Address and Phone Number / Policy Number ______/______
Please Note Any Medical Conditions ______
(Additional) Emergency Contact Name & Phone ______
Circle Jersey Size: YM YL S M L XL XXL ($30.00 Charge for replaced jersey(s))
PLEASE INDICATE IF YOU WOULD LIKE TO VOLUNTEER BY CIRCLING THE FOLLOWING:
HEAD COACH
This program is available to all children ages between 6 and 14.
The registration fee is $130.00 (Includes up to 8 games and Reversible Jersey)
After November 1st$145.00
Questions may be directed to Khalid Hicks (831)840-9166
Send completed form and fees to:
Got Game? Get Game! Youth Basketball
6929 Axis Street SE, Lacey, WA 98513
PLEASE READ CAREFULLY AND SIGN:
______has my permission to participate in Got Game? Get Game!Youth basketball program. I certify that my child is fully capable of participating in the designated sport and that my child is healthy and has no physical or mental disabilities or infirmities that would restrict full participation in these activities. I understand that there are certain risks of injury inherent in the practice and play of this sport, as well as in traveling and other related activities incidental to my child's participation, and I am willing to assume these risks on behalf of my child. In the event of an injury to my child, I hereby give Got Game? Get Game! or North Thurston Public School permission to arrange transportation for my child to a medical facility, and/or to provide my child with emergency treatment or first aid. I understand that the North Thurston Public School does not assume any responsibility to take any of these actions. I give permission for my child to be treated by a licensed physician and for the said physician to administer whatever care is necessary, including anesthesia for their safety and care. The child’s family will be responsible for all of the associated medical expenses. I waive and release any right and claims I may have against the Got Game? Get Game! Youth League employees orNorth Thurston Public School and all members of the North Thurston Public Schoolor Got Game? Get Game! Youth basketball programs for any and all damages which may be suffered by my child in connection with his/her association with the program. I accept responsibility for returning any and all equipment used by my child to the North Thurston Public School or agree to replace it.
SIGNATURE OF PARENT______
DATE______
Requested Teammates and/or Team
1.______
2.______
3.______
4.______
Release Authorization from Emergency Treatment
I understand that I am required to maintain and carry accident medical insurance coverage for the child listed on this application and I verify that the coverage information attached herewith is accurate and true.
In case of emergency and if I cannot be reached, I authorize the staff of the Got Game? Get Game! Youth League and /or North Thurston Public School to obtain whatever medical treatment they deem necessary for the welfare of my child listed on this application. I further understand that I will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment, regardless of whether or not my medical insurance would cover such charges and fees.
I am the parent/guardian of the minor ______
And I am signing this RELEASE on behalf of said minor.
Signature of Parent/Guardian of MinorDate
Name of Medical Insurance CarrierPolicy Number
Waiver of Liability, Assumption of Risk and Indemnity Agreement
Waiver: In consideration of being permitted to participate in any way in the Got Game? Get Game! Youth League, I , for myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, and covenant not to sue the Got Game? Get Game! Youth League orNorth Thurston Public School, its officers, employees, and agents from liability from any and all claims include negligence of the Got Game? Get Game! Youth League or/andNorth Thurston Public School, its officers, employees and agents, resulting in personal injury, not limited to participation in Got Game? Get Game! Youth League.
Assumption of Risks: Participation in the Got Game? Get Game! Youth League carriers with it certain inherent risk that cannot be eliminated regardless of the care taken to avoid injuries. The specific risk range from 1) minor injuries such as scratches, bruises, and sprains to 2) major injuries such as eye injury or loss of sight, joint or back injuries, heart attacks, and concussion to 3) catastrophic injuries including paralysis and death.
I have read the previous paragraph and I know, understand, and appreciate these and other risk that are inherent in the Got Game? Get Game! Youth League. I hereby assert that my participation is voluntary and I knowingly assume all such risk.
Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD the Got Game? Get Game! Youth League and/or North Thurston Public School HARMLESS from any and all claims, actions, suits, procedures, cost, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement in the North Thurston Public School and to reimburse them for any such expenses incurred.
Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risk agreement is intended to be as broad and inclusive as is permitted by the law of the State of Washington and that if any portion thereof is held invalid, it is agreed that he balance shall, notwithstanding, continue in full legal force and effect.
Acknowledge of Understanding: I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understanding its terms, and understanding that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be complete and unconditional release of all liability to the greatest extent allowed by law.
Signature of Parent/Guardian of MinorDate
Name of Medical Insurance CarrierPolicy Number