Loading...

Waiver and Photo Release Forms
Hollywood Dodgers Lil Hoopster Camp

I am aware that basketball is a strenuous sport and that participation in basketball games, training, and conditioning can result in physical injury such as sprains, broken bones, head injuries, and on occasion, even death. I am fully familiar with my child's medical and physical condition. My child has no illness or other medical condition which prevents him or her from fully participating in a vigorous sport such as basketball or which would be aggravated or exacerbated by or otherwise result in a worsening of my child's medical or physical condition due to his or her participation in basketball games, training or conditioning. I understand the coaches, assistant coaches, parents and other team members acting in such capacities or the capacity of activity supervisors will rely on the foregoing representation. For and in consideration of my child being permitted to participate in Hollywood Dodgers and its affiliated organizations, and in their basketball games, training and conditioning, I, the undersigned parent or guardian, hereby voluntarily waive, release, discharge, and relinquish for myself and my family, including my child, our heirs, successors, and assigns, any and all liability, claims, suits, actions, or causes of actions against the coaches, assistant coaches, parents, and other team members, for personal injury, death, or property damage occurring to my child arising from my child's participation therein and in any activity incidental thereto wherever or however the same may occur, and whether the same may arise from the negligent acts or omissions of any of said persons, or otherwise.

If it becomes necessary for my child to have medical, surgical, or dental care while participating in any of the aforementioned activities, I hereby authorize the coaches, assistant coaches, parents or team members, acting in such capacities or as activity supervisors, as my agents to consent to medical, surgical, or dental examination and treatment. In case of such emergency, I hereby authorize treatment and care by any physician at any hospital. I understand that any cost incurred for emergency medical, surgical, or dental treatment shall be my sole responsibility.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
Grade*
T-Shirt Size*
Hollywood Dodgers Affiliation*

HD Affiliation Comments

Prior basketball experience and exposure ('none' is acceptable) *

Special Considerations
Does your child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*
No
Yes

If yes, please describe condition
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Grade*
T-Shirt Size*
Hollywood Dodgers Affiliation*

HD Affiliation Comments

Prior basketball experience and exposure ('none' is acceptable) *

Special Considerations
Does your child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*
No
Yes

If yes, please describe condition
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Grade*
T-Shirt Size*
Hollywood Dodgers Affiliation*

HD Affiliation Comments

Prior basketball experience and exposure ('none' is acceptable) *

Special Considerations
Does your child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*
No
Yes

If yes, please describe condition
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Grade*
T-Shirt Size*
Hollywood Dodgers Affiliation*

HD Affiliation Comments

Prior basketball experience and exposure ('none' is acceptable) *

Special Considerations
Does your child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*
No
Yes

If yes, please describe condition
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Grade*
T-Shirt Size*
Hollywood Dodgers Affiliation*

HD Affiliation Comments

Prior basketball experience and exposure ('none' is acceptable) *

Special Considerations
Does your child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*
No
Yes

If yes, please describe condition
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Grade*
T-Shirt Size*
Hollywood Dodgers Affiliation*

HD Affiliation Comments

Prior basketball experience and exposure ('none' is acceptable) *

Special Considerations
Does your child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*
No
Yes

If yes, please describe condition
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Grade*
T-Shirt Size*
Hollywood Dodgers Affiliation*

HD Affiliation Comments

Prior basketball experience and exposure ('none' is acceptable) *

Special Considerations
Does your child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*
No
Yes

If yes, please describe condition
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Grade*
T-Shirt Size*
Hollywood Dodgers Affiliation*

HD Affiliation Comments

Prior basketball experience and exposure ('none' is acceptable) *

Special Considerations
Does your child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*
No
Yes

If yes, please describe condition
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Grade*
T-Shirt Size*
Hollywood Dodgers Affiliation*

HD Affiliation Comments

Prior basketball experience and exposure ('none' is acceptable) *

Special Considerations
Does your child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*
No
Yes

If yes, please describe condition
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Grade*
T-Shirt Size*
Hollywood Dodgers Affiliation*

HD Affiliation Comments

Prior basketball experience and exposure ('none' is acceptable) *

Special Considerations
Does your child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*
No
Yes

If yes, please describe condition
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent's or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Medical Insurance

Insurance Carrier *

Insurance Policy Number *
Photo Release

I, the undersigned, grant permission to the Hollywood Dodgers, Hollywood Dodgers Las Vegas Invitational tournament committee, and/or East-West Optimist to photograph, tape, film, or make an audio recording of my child's participation during Hollywood Dodger activities. I grant the aforementioned groups an irrevocable license to produce, copy, display, perform or otherwise use these materials (including print, home video, CD-ROM, internet and any other electronic medium presently in existence or invented in the future). I also understand that once my image is posted on the Hollywood Dodgers' website, the image can be downloaded by any computer user.  I understand that use of the material is not for commercial purposes, but for the promotion and publication purposes of the Hollywood Dodgers, Hollywood Dodgers Las Vegas Invitational, and/or East-West Optimist. I agree that my child may be identified as a participant in the event being recorded.

I release the Hollywood Dodgers, its officers, coaches, team representatives, the Hollywood Dodgers Las Vegas Invitational tournament committee, and East-West Optimist officers from any liability connected with the publication, reproduction, release or other use of these materials and agree not to bring any claims against them growing out of such publication, release, reproduction or other use of these materials.

I agree that no further consent or approval is needed for any future use of the materials, and waive any payment for the photos, now and in the future.

I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photograph.

I hereby agree to release, defend, and hold harmless the Hollywood Dodgers, Hollywood Dodgers Las Vegas Invitational tournament committee, and East-West Optimist officers and its agents or employees, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

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's or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent's or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent's or Guardian's Information
Grade*
T-Shirt Size*
Hollywood Dodgers Affiliation*

HD Affiliation Comments

Prior basketball experience and exposure ('none' is acceptable) *

Special Considerations
Does your child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*
No
Yes

If yes, please describe condition
Parent's 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. A valid email address is necessary to complete the registration process.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver