A BLAST FROM THE PAST: ALUMNI/ALL STAR CHARITY BASKETBALL GAME REGISTRATION & WAIVER/RELEASE FORM
Petersburg High School Athletics has teamed up with Petersburg High School Alumni and the American Kidney Fund to host A Blast from the Past: Alumni / All Star Charity Basketball Game. All proceeds from the basketball game will benefit the American Kidney Fund.

Petersburg High School Athletic Director, William "Bill" Lawson III, has a personal attachment with the American Kidney Fund and is spearheading this charity basketball game.

William "Bill" Lawson shares his heartfelt experience of being a dialysis patient for nearly 9 years before receiving a kidney transplant while also carrying out the role of head basketball coach, active father, devoted husband and full-time Athletic Director.

Today, there are almost half a million (500,000) dialysis patients in the United States and nearly 100,000 of them are on the waiting list for a kidney (American Kidney Fund). Thirteen (13) people living with kidney failure die everyday waiting for a kidney (American Kidney Fund).

Your participation in the A Blast from the Past Alumni / All Star Charity Basketball Game will help save a life.

Following submission of Registration & Waiver/Release Form, email a professional headshot to 4phssports@gmail.com.

Player Registration Fee $15 (T Shirt included)
Cheerleader Registration Fee $15 (T Shirt Included)
Coach Registration Fee $0

Registration Payment Link: https://www.eventbrite.com/e/a-blast-from-the-past-phs-alumni-all-star-charity-basketball-game-tickets-62186495482

Waiver of Liability and Photography Release

COMPLETING AND SUBMITTING THIS FORM IS AGREEING TO THIS WAIVER OF LIABILITY AND PHOTOGRAPHY RELEASE

I am participating in A Blast from the Past: Alumni / All Star Charity Basketball Game.

I recognize that participating in A Blast from the Past: Alumni / All Star Charity Basketball Game may require physical exertion which may be strenuous and may cause aggravated physical injury, and I am fully aware of and willingly assume the risk and hazards involved. I understand that it is my sole responsibility to consult with a physician prior to my participation in A Blast from the Past: Alumni / All Star Charity Basketball Game.

I represent and warrant that I am physically fit and have no medical condition which would prevent my full participation
in these activities. In consideration of being permitted to participate in A Blast from the Past: Alumni / All Star Charity Basketball Game, I agree to assume full responsibility for any risk, injuries, or damages, known or unknown, which I might incur as a result of participation in the activity.

I agree to inform my coaches of any physical limitations, discomfort and or injuries before or during A Blast from the Past: Alumni / All Star Charity Basketball Game and I take full responsibility for my own actions and my own limitations.

I knowingly, voluntarily and expressly waive, renounce and disclaim any claim I have or may have against A Blast from the Past: Alumni / All Star Charity Basketball Game, its coaches, contractors, organizers, directors, partners, owners, and employees for loss, theft or damage of any personal property from A Blast from the Past: Alumni / All Star Charity Basketball Game premises, for injuries or damages that I may sustain within the A Blast from the Past: Alumni / All Star Charity Basketball Game grounds and/or facility, and/or for injuries or damages that I may sustain as a result of participating in A Blast from the Past: Alumni / All Star Charity Basketball Game.

I forever release, waive, discharge, and covenant not to sue A Blast from the Past: Alumni / All Star Charity Basketball Game for any injury or death caused by their negligence or other acts that are not intended to harm me.

I grant A Blast from the Past: Alumni / All Star Charity Basketball Game and its representatives and employees the right to take photographs and videos of me and my property in connection with the above-identified purposes.

I authorize A Blast from the Past: Alumni / All Star Charity Basketball Game, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that A Blast from the Past: Alumni / All Star Charity Basketball Game may use such photographs and videos of me with or without my name and for any lawful purpose, including but not limited to such purposes as publicity, illustration, advertising, and Web content.

I hereby waive the right to receive any payment for signing this release and waive the right to receive any payment for A Blast from the Past: Alumni / All Star Charity Basketball Game use of any of the material described above for any of the purposes authorized by this release.

Thank you so much for being a part of A Blast from the Past: Alumni / All Star Charity Basketball Game and saving a life.

Please complete the Registration/ Waiver Release Form. It should only take about 3 minutes to complete.

A Blast from the Past: Alumni / All Star Charity Basketball Game

Saturday, July 20, 2019
Petersburg High School
William Lawson, Jr. Gymnasium
3101 Johnson Road
Petersburg, Virginia 23805

Contact: 4phssports@gmail.com

Website: www.phsalumniallstar.com
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