Registration_and_Medical_Release

Gym Rat Basketball, Inc.

Registration and Medical Release Agreement

Last Name:

______________________________

First Name:

______________________________

I, as the parent/guardian acknowledge that the above listed participant is in a state of health, which will allow participation in this physically, demanding activity. I grant permission for the staff of Gym Rat Basketball to take whatever action necessary in the event there is an injury or illness for which they may be unable to reach me. I also understand that I must provide the primary medical insurance in the event coverage is necessary. I hereby waive and release Gym Rat Basketball Inc., its officers, agents and employees, City of Santa Rosa School Districts, its Governing Board, officers, agents and employees from any and all liability for any injuries or illness incurred while participating at a Gym Rat Basketball camp, clinic, league, personal training, practice or class. I also understand that any violation of Gym Rat Basketball rules could result in the dismissal of individuals from the event.

Health Insurance Company: _____________________________________

Policy No.:

________________________

Group No.:

_________________________

________________		______________________________		______________________________
Date		Parent/Guardian Name		Signature

Allergic to medicines? Circle one:

Yes

If ‘Yes,’ please list:

______________________________________________________

Physician:

____________________________________________

Phone:

______________________

Assumption of Risk and Waiver

I, ______________________________, as the parent or guardian of, desire to have ______________________________ voluntarily participate in Gym Rat Basketball Inc. programs. I understand these activities present risks of injury and I expressly assume those risks, and waive and release Gym Rat Basketball Inc., its owners, officers, employees, affiliates and agents, City of Santa Rosa School Districts, its Governing Board, officers, agents and employees.

Like all physical activities and exercise, these activities carry inherent risks of injury. By allowing ______________________________ to participate voluntarily in these activities, I expressly assume all associated risks.

I voluntarily agree to allow ______________________________ to participate in these activities at his/her own risk. I completely release Gym Rat Basketball Inc., its owners, officers, employees, agents and affiliates, City of Santa Rosa School Districts, its Governing Board, officers, agents and employees from any responsibility for personal injuries or property loss or damage that may be sustained in the course of or due to these activities.

________________	______________________________	______________________________
Date	Parent/Guardian Name	Signature

________________	______________________________	______________________________
Date	Witness Name	Signature

To: Emergency Medical Staff/Physician

I hereby authorize the staff of Gym Rat Basketball to act for me according to their judgment regarding emergency treatment for my child in the event they are unable to reach me.

________________		______________________________		______________________________
Date		Parent/Guardian Name		Signature

Payment for:

League

_____

Camp

_____

Additional information (optional):

Primary Phone:

______________________

Other Phone:

______________________

Street Address:

____________________________________

City:

________________________

ZIP:

____________

Primary Email:

_________________________________

Other Email:

____________________________________

School:

_________________________

School Grade:

_____

Date of Birth:

_________________________

Mail to: Gym Rat Basketball · 1816 Palisades Drive · Santa Rosa, CA 95403