NLBA Participation Form
Athlete's First Name
Athlete's Last Name
Parent / Guardian First Name(s)
Parent / Guardian Last Name(s)
Date of Birth (mm/dd/yyyy)
Emergency Contact Name
Emergency Contact Number
Health Card Number
What is their current level of play?
T-Shirt / Jersey Size
Waiver of Liability
NOTICE: This is a legally binding document.
In consideration of being allowed to participate in any way in Northern Lights Basketball Academy (NLBA), related events and activities, the undersigned acknowledges, appreciates, and agrees that;
1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment and personal discipline may reduce this risk, the risk of serious injury does exist; and,
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation. If however I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and,
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release and hold harmless NLBA their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event with respect to any and all injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the releases or otherwise.
I HAVE HAD SUFFICIENT OPPORTUNITY TO READ THIS ENTIRE DOCUMENT. I HAVE READ AND UNDERSTOOD IT, AND I AGREE TO BE BOUND BY ITS TERMS.
Does your son/daughter have any allergies?
If yes, please explain
Does your son/daughter have any health concerns we should be aware of?
If yes, please explain.
I agree to grant to Northern Lights Basketball Academy (NLBA) and its authorized representatives permission to record on photography film and/or video, pictures of my participation, this includes electronic images and media as well. I further agree that any or all of the material photographed may be used, in any form, as part of any future publications, brochure, or other printed materials and electronic media used to promote NLBA, and further that such use shall be without payment of fees, royalties, special credit or other compensation.
Do you accept the above terms?
PayPal on NLBA Website
Small Group Training
A copy of your responses will be emailed to the address you provided.
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