Camper Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 1 Name *

First Name

Last Name

Parent/Guardian 1 Phone *

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Parent/Guardian 2 Name

First Name

Last Name

Parent/Guardian 2 Phone

(###)

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Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

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Release of Liability *

ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM I hereby assume all of the risks of participating in Illinois Basketball Club & IBC Foundation, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them, or because of their possible liability without fault. I certify that I am physically fit and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this basketball program. I acknowledge that this Accident Waiver and Release of Liability Form will be used by the organizers of Illinois Basketball Club & IBC Foundation in which I may participate and that it will govern my actions and responsibilities. In consideration of my application and permitting me to participate in Illinois Basketball Club & IBC Foundation, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A)I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from Illinois Basketball Club & IBC Foundation activities and events. THE FOLLOWING ENTITIES OR PERSONS: Illinois Basketball Club & IBC Foundation and/or their coaches, agents, representatives, directors, partners or volunteers. (B) I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in Illinois Basketball Club & IBC Foundation, whether caused by negligence or otherwise. I acknowledge that Illinois Basketball Club & IBC Foundation may carry with it the potential for death, serious injury, and personal loss. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, and lack of hydration. I consent and agree that Illinois Basketball Club & IBC Foundation and/or their coaches, agents, representatives, directors, partners or volunteers may take photographs or digital recordings of me as I participant during this event and use these in any and all media for training or promotional purposes. I further consent that my identity may be revealed therein or by description text or commentary. I waive any rights, claims or interest and I understand that there will be no financial or other remuneration. The accident waiver, release of liability and image release shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT ON MY OWN FREE WILL.

I Consent

I Do Not Consent

Person giving consent *

First Name

Last Name