Player Name *

First Name

Last Name

Player Birth Date *

MM

DD

YYYY

Player Phone

If different from parent/guardian phone

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent 1 Name *

First Name

Last Name

Parent 1 Phone *

(###)

###

####

Parent 2 Name

First Name

Last Name

Parent 2 Phone

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Are there any injuries requiring medical attention? *

YES

NO

Are there any scheduled surgeries? *

YES

NO

Is the participant currently taking any medications? *

YES

NO

Does the participant have any allergies (penicillin, bee stings, etc)? *

YES

NO

Does the participant have asthma/require the use of an inhaler? *

YES

NO

Is the participant diabetic/require medication for diabetes? *

YES

NO

Does the participant have seizures? *

YES

NO

Does the participant wear glasses or contact lenses? *

YES

NO

Does the participant wear a brace or other medical support device? *

YES

NO

Does the participant have any other physical limitations or medical conditions? *

YES

NO

*

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

*

1. I will encourage good sportsmanship by demonstrating and modeling positive support for all players, coaches and officials at every game, practice, and other related events. I will place the emotional and physical well-being of my child ahead of any personal desire to win. 2. I will insist that my child play in a safe and healthy environment. 3. I will demand a drug, alcohol and tobacco free sport environment for my child and agree to assist by refraining from their use in and around the playing facilities. 4. I will remember that the game is for the children and not for the adults. 5. I will do my very best to make basketball fun for my child. 6. I will ask my child to treat other players, coaches, fans, and officials with respect, regardless of race, sex, creed or ability. 7. I will make every effort for my child to attend all practices and games and I will give proper notification to the coach(es) if they are unable to attend. Furthermore, I will ensure that my child is dropped off and picked up promptly at the appropriate times. 8. I will see that players fees are paid in full on the appropriate due dates.

I Consent

I Do Not Consent

Person Giving Consent *

First Name

Last Name

*

1. ALL PRACTICES ARE MANDATORY Please communicate valid reasons for being absent or tardy with your coach(es) before the start of practice. Three (3) unexcused absences or late arrivals may result in suspension from games or removal from the roster. 2. POSITIVE BEHAVIOR + POSITIVE ATTITUDES Illinois Basketball Club will only tolerate positive behavior and attitudes towards fellow teammates, coaches, other adults (including parents), other teams, fans and referees. Negative behavior and/or foul language will not be tolerated. 3. PRACTICE STARTS AND ENDS PROMPTLY ON TIME Parents, please ensure that your player has reliable, prompt transportation to and from practice. 4. 100% EFFORT 100% OF THE TIME Coaches expect all players to play their hardest and try their best at all times. We don’t expect perfect results, but we do expect a perfect effort. 5. UNIFORMS ARE ONLY FOR GAMES Game uniforms should only be worn during games. At the conclusion of the season, athletes can wear their uniform as they wish.

I Consent

I Do Not Consent

Person Giving Consent *

First Name

Last Name

*

I, as parent or legal guardian, give permission for my child’s picture and/or video footage to be used in all media and marketing materials including, but not limited to social media sites, print material, and www.ilbasketballclub.com.

I Consent

I Do Not Consent

Person Giving Consent *

First Name

Last Name