Participant's Name *

First Name

Last Name

Participant's Date of Birth *

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DD

YYYY

Address *

Address 1

Address 2

City

State/Province

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Country

Parent/Legal Guardian's Name *

First Name

Last Name

Phone

(###)

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WAIVER OF LIABILITY AND RELEASE - I have authority to make decisions for the participant listed above. I am aware of the physical nature of basketball activities and I hereby assume responsibility for the above listed participant. I will not hold EIQ Basketball Academy and/or its employees responsible in the case of accident or injury as a result of this participation. By clicking "I agree" below, I agree to these terms. *

I affirm and agree

I give EIQ Basketball Academy permission to photograph the participant listed above and use the likeness for news media and promotion.

I affirm and agree