ELW Future Stars - Summer 2019 Basketball League Waiver
Presented by: Eddie Lee Wilkins Youth Association, Inc.
POST OFFICE BOX 722 | CARTERSVILLLE, GEORGIA 30120
(404) 725-3376 (phone) | infoelwyouth@gmail.com (email)

PARTICIPATION WAVIER FORM
Fee: $50.00 (Bartow County residents) | $65.00 (Non-residents)

Email address *
Participant
Name
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Team
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School
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Age
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Birthdate
MM
/
DD
/
YYYY
Height
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Weight
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Race
Your answer
Sex
Street Address
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City
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Zipcode
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Phone number
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Phone type
Email *
Your answer
Do you have any Medical problem such as illness, physical disability, or deformity, etc. If yes, explain:
Your answer
Parent/Guardian
Name
Your answer
Phone number
Your answer
Phone type
Email *
Your answer
Medical Waiver
I, the parent (guardian) of above named individual, hereby give my permission for his/her participation in the Eddie Lee Wilkins Youth Association, Inc. sponsored “ELW Future Stars Summer League” and all related activities. I assume all risks and hazards inherent and incidental to the conduct of the activities. I also hereby release, absolve, indemnify, waive all claims and hold harmless the Eddie Lee Wilkins Youth Association, Inc., the Organizers, Supervisors, Employees, Volunteers, Sponsors, and Facility Providers, including but not limited to the Etowah Area Consolidated Housing Authority, Cartersville City School Board, City of Cartersville and Government, and other locations where ELW basketball games are played. I also release from responsibility any person transporting above named individual to or from the doctor or hospital in case of an injury. All above holds true as long as above named individual participates in the Eddie Lee Wilkins Youth Association, Inc. sponsored program or related activity. I also understand the cost to participate in the Future Stars Basketball League is $50.00 for Bartow County residents and $65.00 for non-residents and
Primary physician
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Physician phone number
Your answer
Insurance provider
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Policy # / Group #
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APPROVAL FOR PARTICIPATION
The above named has my approval to participate in the Future Stars Summer Basketball League, with the understanding that above named is required to participate in on-site Social Intervention seminars, as well as life skills and motivational sessions.
Parent/Guardian signature (type full name) *
Your answer
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