Kids Venice Basketball League Summer 2015 Registration Form

Kids Venice Basketball League Summer 2015 Registration Form
Camp Dates: 6/7,14,21, 7/5,12,19,26, 8/9, 16, 23, 30, 9/6 Age: 6-13
Participant Information
Participant Name *

First Name Last Name
Birth Date *

Month Day Year
Grade
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent/Guardian Information
Name *

First Name Last Name
Home Number *

Area Code Phone Number
Cell Number

Area Code Phone Number
E-mail *
Emergency Information
Emergency Contact's Name *

First Name Last Name
Relationship *
Phone Number *

Area Code Phone Number
Alt. Phone Number

Area Code Phone Number
Package
prev next ( X )
One Time $ 50.00

5 Session Package $ 200.00

All Summer Package $ 350.00

Total $ 0.00
Participation Date(s)

6/7/2015 6/14/2015 6/21/2015 7/5/2015 7/12/2015 7/19/2015 7/26/2015 8/9/2015 8/16/2015 8/23/2015 8/30/2015 9/6/2015
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Veniceball during the selected clinics. In exchange for the acceptance of said child’s candidacy by Veniceball, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Veniceball 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 clinic sessions.

In case of injury to said child, I hereby waive all claims against Veniceball 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.
Standard/Minor Release

I, hereby confirm that I have agreed voluntarily to appear without compensation in the above-identified video program produced by Veniceball, I agree that the program(s) may be broadcast and distributed without limitation through any means and I shall not receive any compensation for my participation during the entire league broadcast. I confirm that any and all material furnished by me for this program is either my own or otherwise authorized for such use without obligation to me or any third party. I also agree to the use of my name, likeness, portrait or pictures, voice and biographical material about me for educational, program or series publicity and organizational promotional purposes. I further agree that my participation in the program confers upon me no rights to use, ownership or copyright. I release Veniceball, its employees, agents, and assigns from all liability which may arise from any and/or all claims by me or any third party in connection with my participation in the program(s). It is understood that Veniceball is under no obligation to broadcast the above-identified program(s) or series.
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.
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Kids Venice Basketball League Summer 2015 Registration Form

Camp Dates: 6/7,14,21, 7/5,12,19,26, 8/9, 16, 23, 30, 9/6 Age: 6-13