Cool Hoops Waiver Form

Attendee Name

Date of Birth

Sex MaleFemale

Age

Parent/Guardian

Home Phone

Work Phone

Home Address

City

State

Zip

IF NOT AVAILABLE IN ANY EMERGENCY, NOTIFY:

Emergency Contact Phone

Emergency Contact Phone

Name of Family Doctor Phone

Allergies/Medications

Special Conditions

Insurance Company

Policy No. Group No.

MUST BE COMPLETED FOR ATTENDANCE

PARENT'S AUTHORIZATION: This health history is correct so far as I know and the person herein described has permission to engage in all prescribed camp activities except as noted by me and the examining physician. I hereby give my permission to the physician selected by the camp director to order X-rays, routine tests and treatment for the health of my child and in the event I cannot be reached in an emergency. I understand that basketball is a physical activity and a contact sport. Cool Hoops has informed me that during this activity, there is a possibility of serious injury or death. I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above. I also understand that we are responsible to have coverage with Blue Cross, Blue Shield or another commercial insurance carrier. I also waive Cool Hoops LLC of any responsibility to pay for hospital bills or insurance expenses.

Signature of Parent/Guardian


Date

The camper and his/her parents agree to abide by the rules and regulations set up by the Camp for health, safety and welfare of the Camp. The following violations of camp rules will result in immediate dismissal from the camp without refund of camp fee:
1) Leaving campgrounds without permission.
2) Willful destruction of camp property.
3) Use of drugs and/or alcoholic beverages.
4) Fighting and/or continued insubordinate behavior resulting in disrupting of the camp program.

Camper's Signature

Date

If it is necessary, in the judgment of the camp, to use outside medical, surgical or dental aid for the camper's health, all such expenses shall be paid by the parent, unless covered by parent or guardian's insurance. The camp is not responsible for articles of clothing or personal belongings lost or damaged by theft, laundry or otherwise except if accepted by the camp director personally for safekeeping. If the parent cannot be reached in case of emergency, the camp is authorized to use its own judgment in any situation. The camp is given permission to use all pictures taken during my child's stay at camp for any advertising. The parent gives permission to Cool Hoops for the son/daughter to travel in all licensed camp vehicles during the course of the regular camp session. This also includes buses that are used on rainy days to our other indoor facilities.

Signature of Parent/Guardian


Date