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Hoops4Health Waiver Form

TODAY'S DATE: March 20, 2019

I hereby authorize (the child), to participate in the programs of Hoops 4 Health, Inc. (Hoops). Further, I authorize Hoops to act for me and exercise best judgment in any emergency requiring medical attention for the child. I hereby waive and release Hoops from any and all liability for any injury or illness incurred by the child while participating in any program of Hoops. I understand that Hoops 4 Health, Inc. (Hoops) may take photographs and/or video of the child while participating in any and all activities connected with the programs of Hoops. Accordingly, I agree that Hoops retains the right to use for publicity and advertising any such photographs. As the parent or guardian of the child, I recognize and acknowledge that there are certain risks of physical injury and agree to assume the full risk of any injuries, including death, damages or loss which the child may sustain as a result of participating in any and all activities connected with the programs of Hoops. Accordingly, I agree to waive and relinquish all claims I or the child may have a result of participation in any program of Hoops against Hoops, its officers, agents, and employees from any and all injuries, including death, damage or loss which I or the child may have or which may accrue as a result of childs participation in any program of Hoops.

Please select who will be participating...
Minor
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First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Persons to contact in case of emergency

Parent's or guardian's information:


Name:

Home Phone:

Cell Phone:

Work Phone:

Address:

Second Person's Information:


Name:

Home Phone:

Cell Phone:

Work Phone:

Address:

Email:
Medical Information

List all of the child's past and present health issues that may affect the child's participation in any program of Hoops4 Health
Does the child have any allergies (e.g., food allergies, bee stings or dust)?*

If yes, explain:

Does the child have: (check all that apply)

Asthma
Diabetes
Epilepsy
Does the child take any medications?*

If Yes, name them:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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