LOCATION *

Black Walnut Public School

PARENT OR GUARDIAN NAME *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

1st child's name

First Name

Last Name

2nd child's name

First Name

Last Name

3rd child's name

First Name

Last Name

Waiver *

RELEASE AND WAIVER OF LIABILITY I give permission for my child to participate in all activities involved with this program, and hereby release NHB, its facilities, staff, and proprietors from any liability or responsibility from any injury or illness that may occur during participation. I am aware of the inherent risks involved with the physical nature of this program, and hereby attest that my child has been deemed by a physician to be in suitable physical and medical condition for participation in rigorous physical activity. If I am unable to be reached in the event that my child should require emergency medical treatment or care, I authorize NHB and its representatives to seek appropriate medical treatment or care for my child on my behalf.

I accept

I do not accept

Photo consent *

Photo Consent * PHOTO CONSENT I hereby give permission to New Horizon Basketball Academy to include my child in photos and video taken by the New Horizon staff. I understand these photos will be used for publicity and promotional purposes only (e.g. website, social media, brochures, educational or community events, etc), but no names will be associated with pictures and/or video without permission from parent(s) or guardian(s).

I consent

I do not consent