IMPACT ATHLETICS

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Impact Athletics Summer Basketball League

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Birthdate:

Email:

Gender:

Grade:

PARENT/GUARDIAN #1

Firstname:

Lastname:

EMail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

WAIVER INFORMATION

*** Insert your waiver information here ***

Waiver of Liability, Assumption of Risk and Indemnity Agreement for Impact Athletics
With a full understntial risks, I hereby assume the risks of participating in a basketball
contest event. I acknowledge that my participation in Impact Athletics is voluntary
and carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid
injuries. The specific risks vary from one activity to another. Risks range from: minor injuries such as
scratches, bruises, and sprains to major injuries such as eye injuries, back injuries, broken bones or
concussions, to catastrophic injuries including paralysis and death.
On behalf of myself, my executors, administrators, heirs, next of kin, successors and assigns, I hereby waive,
release and forever discharge Impact Athletics, its members, directors, officers,
sponsors, volunteers or representatives of any of the foregoing: from any and all claims or liabilities for death,
personal injury or damage of any kind or nature whatsoever which arise out of or related to my participation
in the Impact Athletics.
As evidence of my signature, I certify that I have read and understand the foregoing waiver and release of
liability, that I understand that I am giving up substantial rights by signing this waiver and release of liability,
that I intend to be bound by the terms of the foregoing waiver and release

I/we agree with the above *

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Impact Athletics Summer Basketball League