3-on-3 THE LAB Basketball Registration Form

Participant Information

Athlete's Name *

PrefixFirst NameLast Name

Date of Birth*

MonthDayYear

Parent/Guardian Name *

PrefixFirst NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone Number*

Area CodePhone Number

Cell Phone Number*

Area CodePhone Number

E-mail*

Emergency Contact & Information

Emergency Contact Name *

PrefixFirst NameLast Name

Relationship to Participant*

Emergency Contact Number*

Area CodePhone Number

Does your child have any allergies, chronic illness, or medical conditions that would limit high level activity?*

* This schedule is subject to change. Changes, if necessary, will be announced in class, e-mailed to distribution group, and updated here.

Photo and Video Consent

For internal documentation and marketing purposes, photographs and videos may be taken while your child/children are participating in THE LAB Basketball activities/programs. The images will remain the property of THE LAB Basketball and may be used by THE LAB Basketball to promote the program internally and externally including in social media and advertisements. I give / do not give my permission for my child/children to be photographed and videotaped by THE LAB Basketball appointed photographer and cameraman for the purposes of documentation and marketing purposes.*

YESNO

Electronic Waiver and Release of Liability

I am the parent/guardian of the child register herein. I hereby certify that my child/dependent that I am registering to participate in the THE LAB Basketball activities/programs does not have any pre-existing conditions, chronic illness, medical conditions, or injuries that would preclude him/her from participating. Sports participation requires an acceptance that an athlete may sustain a catastrophic injury and/or death. With this understanding, I hereby discharge, waive, and release THE LAB Basketball, its trainers, staff, and sponsors, from all liabilities or claims for damages or injuries and/or death that may be sustained or may occur by my child resulting from participation in THE LAB Basketball activities/programs.*

I have read and agree to the terms of the event waiver and disclaimer stated above

Parent/Guardian Signature*

3-on-3 Registration Form