Boys Basketball Clinic

Child's Name*

Child First Name Child Last Name

Child Birth Date*

Month Day Year

Phone Number

Parent's Name*

First Name Last Name

Parent's Phone Number*

E-mail*

MEDICAL RELEASE

I hereby give consent to the administration of Boys Basketball Clinic to take whatever medical measures they deem necessary, at my expense, for my child in the event of a medical emergency. I understand that, when possible, every effort will be made to contact parent/guardian or emergency contact before Boys Basketball Clinic will undertake such decision.

Signature of Parent or Guardian*

Date & Time

Month Day Year

at Hour Minutes

My child/ren is permitted to be given Children's Tylenol, Motrin or similar:*

YesNo

Is your child/ren allergic to any medications?*

YesNo

Please specify medical allergies.*

Please specify food allergies.*

Is your child/ren up to date on all immunizations?

YesNo

Does your child/ren have a medical, developmental or emotional condition that we should be aware of?*

YesNo

Please specify condition(s).*

Basketball Experience* Please specify past/current experience

Comments

TERMS AND CONDITIONS

PARENTAL CONSENT: I hereby give consent for my child to participate in all activities of Boys Basketball Clinic both on and off site, unless I advise you otherwise in writing.

PAYMENT AND CANCELATION: Payment terms are a $18.00 non-refundable registration fee per participant.

In the event that camp is unable to open all fees will be refunded.

DISMISSAL OF PARTICIPANT: Parent fully understands and agrees that the Clinic reserves the right to dismiss, in its sole discretion, any Participant whose condition, conduct, influence or behavior is deemed unsatisfactory or detrimental to the best interests of the Clinic or fellow participants or who violates clinic rules and regulations. In the event of dismissal, tuition will be refunded on a pro-rated basis less the registration fee.

IMAGES, ETC.: Permission is hereby given to use in promoting the Clinic and in other ventures directly relating to the Clinic (i) digital, photographic and video images or likenesses of camper; audio of camper; and (ii) statements, articles, names, music, art, photographs, audio recordings, films and videos created by camper or originating from Clinic or from a Clinic-related activity.

INDEMNIFY & HOLD HARMLESS: I recognize the inherent risk of injury in sports activities. I further release and agree to indemnify and hold harmless Chabad Lubavitch of Idaho, Chabad Jewish Center, Boys Basketball Clinic and its officers, servants, volunteers, or assigns from any liability concerning my child’s involvement in Boys Basketball Clinic and further agree that the use of any premises during the Boys Basketball Clinic is made at the risk of the participant.

I have read and agree to all of the terms and conditions in this Application Form. I am including a non-refundable $18.00 registration fee per camper along with submission of this form.

Signature of Parent or Guardian*

Date & Time*

Month Day Year

at Hour Minutes

Amount*

$18

Payment

Credit Card Paypal

Postal / Zip Code

Country

I would like to receive news and updates by email

Boys Basketball Clinic

Synagogue Services

Adult Education

Youth Programs

Holiday Celebrations

Women's Circle

Shabbat