REGISTRATION FORM | THE PENNY WAY, LLC

EMERGENCY CONTACT/RELATIONSHIP *

NAME *

AGE *

ADDRESS *

PHONE NUMBER *

SCHOOL *

GRADE *

EMAIL ADDRESS *

M/F *

EMERGENCY PHONE *

PREFERRED HOSPITAL *

MEDICAL CONDITIONS *If your child has any additional medical needs, please bring this to the attention of the instructors *

DATE / LOCATION *

11/17- (AGES 8-10)/PERU

TIME *

9A-11A (AGES 8-10)/PERU

Agreement, Waiver and Release for Minor

I am aware that participation in The Penny Way Basketball Camp has some inherent risks and injury that can occur. I hereby authorize the staff of The Penny Way Basketball Camp to act for me according to their best judgment in any emergency requiring medical attention to my son/daughter. I waive and release The Penny Way Basketball staff, its coaches and volunteers from any and all claims for personal injury. I will be responsible for any medical or other charges in connection with his/her involvement in the program. I hereby give consent to allow photographs of said minor. I understand the pictures may be used by The Penny Way Basketball Camp. I attest I am eighteen years or older and that my child is physically fit and have no known medical conditions which prohibit participation in this sport. I have read this waiver and agree to the contents.

PARENT/GUARDIAN SIGNATURE *