2012 Spring Group Workouts Registration Form | Hoop Dreams with Chris Herren

2012 Spring Group Workouts Registration

Player Information:

Player Name (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Contact Phone (required)

Email (required)

Workout Group

Player's Age (required)

Player's Grade/School (required)

Medical Information:

Allergies / Medical Conditions (required)

Doctor (required)

Doctor's Phone (required)

Insurance Company (required)

Insurance Policy # (required)

Emergency Contact (required)

Relationship (required)

Emergency Contact Phone (required)

Waivers: (Please Check Boxes)

Parental Release and Consent

I hereby give approval for the participation of my child in Hoop Dreams with Chris Herren Clinics and Camps and I assume all risk and hazards incident to such participation including transportation to and from said activities. I/We waive, release, absolve, indemnify, defend and agree to hold harmless Hoop Dreams with Chris Herren, Inc., the organizers, the officers, the board of directors, participants, officials, and persons from such activities form any claims arising out of injury to my child.

Medical Release and Permission

I/We do hereby authorize any person in a responsible position within Hoop Dreams with Chris Herren, Inc., in the event of an emergency, to authorize emergency medical treatment for my child named herein. I/We agree to hold harmless such persons and such emergency care centers for such act and agree to assume financial responsibility for said treatment.

Photo/Participant Waiver

I hereby give approval for Hoop Dreams with Chris Herren, Inc. to use photos and/or the name of my child for and in promotional and advertising materials.

Payment Method (required)