FCA PowerKids-Is He in YOU - BasketballRegistration

FCA PowerKids-Is He in YOU

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PowerKids Basketball Registraion Form

Name of Athlete*
Birthdate*
Grade*
School
Church Attend (If Applicable)
Parent*
Address*
City*
State
Zip*
Home Phone*
Email*
Emergency Phone*
T-Shirt Size
Special Instructions

Payment Options*	Check (mail to address below) Cash (bring first day of camp) Credit Card (click on CC Payment to left ) Scholarship Request (please email jerejohnson@fca.org)

MUST READ - Please read the waiver below, enter your name and check box

In return for my child (?Participant?) being allowed to participate in the FCA PowerKids (the ?Program?), I release and agree not to sue FCA, FCA PowerKids, School District 47, School District 155, Regional Sports Center, KICKS, or the Crystal Lake Park District and their employees, sub-contractors, sponsors, agents, and affiliates from all present and future claims that may be made by the Participant or me, my family, estate, heirs or assigns for property damage, personal injury, or wrongful death arising as a result of the Participant?s participation in the Program and caused by the ordinary negligence of the parties listed above, wherever, whenever, however the same may occur. I understand and agree that those listed above are not responsible for any injury or property damage arising out of the Program, even if caused by their ordinary negligence. I understand that participation in the Program involves certain risks, including, but not limited to, serious injury. I am voluntarily allowing Participant to participate in the Program with knowledge of the danger involved and agree to accept all risks of such participation. I certify that the Participant is in excellent physical health, has received a physical examination within one year of participation in the program and may participate in strenuous and hazardous physical activities, including training activities and exercises to be conducted in the Program. Permission is granted for Participant to receive emergency medical treatment, if needed. I also agree to indemnify and hold harmless those listed above for all claims arising out of participation in the Program and all related activities. I agree to let the parties use Participant?s likeness free of charge in any manner and for any purpose without compensation to me or Participant. I understand that this document is intended to be as broad and inclusive as permitted by law of the state in which the Program is taking place and agree that if any portion of this Agreement is invalid, the remainder will continue in full legal force and effect. I am the parent or legal guardian of the Participant. I am of legal age and am freely signing this Agreement. I have read this form and understand that by signing this form, I am giving up legal rights and remedies. I represent that I am a parent/legal guardian of the person named above and I agree that the terms of this release are binding on me and the child.
Parent/Guardian
	I hereby agree to the above waiver information.

* indicates a required field

Mailing Address
FCA PowerKids
P.O. Box 373
Crystal Lake, IL 60039

Office (815)274-4322

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