Food Desert Survey Registration Page

STUDENT INFORMATION

Name (required)

Birth Date

School

What is your grade level?
 Freshman Sophomore Junior Senior

Student Athlete?
 yes no

If you play sports, what sports do you play?

Your Email (required)

Home Address

PARENT OR GUARDIAN INFORMATION

Name (required)

Phone Number

EMERGENCY CONTACT INFORMATION

Name (required)

Phone Number

PARENTAL CONSENT AND ACKNOWLEDGEMENT

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by SAFEO, during this Basketball Camp. In exchange for the acceptance of said child’s candidacy by SAFEO. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless SAFEO. All its respective officers, agents, and representatives from any and all liability for injuries to the said child arising out of traveling to, participating in, or returning from selected basketball camp sessions.

In case of injury to said child, I hereby waive all claims against SAFEO. Including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include but are not limited to, the risk of fractures, paralysis, or death.

Confirmation

By Entering my full name in the field below and checking the consent box, I am delivering an electronic signature that will have the same effect as an original manual paper signature. The electronic signature will be equally as binding as an original manual paper signature.

I, , consent to the conditions outlined above.

Comments are closed