Hoops for Hope. Team Registra on Packet. Team Division (check one): 10th 12th grade (as of me of tournament)

Transcription

1 December 8, on-3 Hoops for Hope Basketball Tournament Team Registra on Packet Team Team Division (check one): 8th 9th grade (as of me of tournament) 10th 12th grade (as of me of tournament) Athlete 1 Athlete 2 Athlete 3 This list of materials are due to WJCC no later than December 1. Space is limited and will not Checklist: be reserved un l checklist is complete and all materials have been received. This completed cover sheet Forms can be faxed to , ed Athlete 1 registra on form and waiver to WJCCMaccabiLA@westsidejcc.org, Athlete 2 registra on form and waiver or dropped off in person at WJCC s front office, Monday Thursday, between 9:00am 4:30pm. Athlete 3 registra on form and waiver Payment form + $60 payment (or $30 Once your completed forms have been payment and 3 NEW pairs of teen/adultsized submi ed, we will confirm receipt and reserve a space for your team. jeans) Event made possible by the generous support of the The Jeff Feinberg Foundation

2 3-on-3 Tournament: Hoops For Hope Athlete Registration and Waiver (ATHLETE 1) Completed forms can be ed or faxed to WJCC by Sunday, December 1, Space is limited and all teams will be accepted on first come, first serve basis when ALL registration material is completed COMPLETE registration requires a completed version of this form FOR EACH ATHLETE PARTICIPATING ON TEAM, + $60 registration fee ($60/entire team). WJCCMaccabiLA@westsidejcc.org. Fax: **Please do not forget to sign the form on the back** Athlete 1 Birthdate: Age (as of July 31, 2014): Gender (M/F): Grade: School: T-Shirt Size: Athlete s Cell: Athlete s PARENT INFORMATION Primary contact is: Parent # 1 Parent # 2 Both PARENT #1 PARENT #2 Emergency Contact: Relation: Phone: Doctor s Phone: Insurance Carrier: Policy Holder Plan #: Insurance Carrier Ph. #: Special Needs/Allergies/Medical Issues: Required waiver continued on back 1

3 Athlete 1 Waiver Eligibility I understand that my child must be between in the grade indicated on the front of the registration packet on date of the tournament, and that a school ID may be required to prove eligibility. Fees Total cost of participation in the 3-on-3 tournament is $60/team (or $30/team + 3 NEW pairs of teen/adult-sized jeans). While this can be broken up amongst athletes on the team, to register team will need to submit full $60 in one payment (one check or credit card, or $60 cash). As of Dec.1 registration deadline, this fee is non-refundable. Waiver Parent or guardian agrees to and does hereby indemnify and hold, their individual units, its officers, directors, agents, professional staff, volunteers and its other employees harmless from and against any and all claims, damages, costs, expenses, causes of actions and liabilities for any injury to or death of any person or persons, including the above-mentioned child, himself/herself, or damage to or loss of any property resulting from participation in this program, not withstanding that same may have been caused by any action or inaction, commission or omission, including, but not limited to the negligence of any of the aforesaid or otherwise. Medical Treatment The undersigned parent or guardian certifies that the child is healthy and able to participate in this program at the time of registration. Parent or guardian gives permission to secure proper medical treatment in case of emergency, where parent or guardian cannot be reached. Publicity Parent or guardian permits the use of child s name and/or photographs for publicity, this includes online marketing/publicity (including but not limited to WJCC s website, listserv and Facebook page). I have read the above statement, accept all terms & completed this form to the best of my ability. Parent or Guardian: Signature Date: 2

4 3-on-3 Tournament: Hoops For Hope Athlete Registration and Waiver (ATHLETE 2) Completed forms can be ed or faxed to WJCC by Sunday, December 1, Space is limited and all teams will be accepted on first come, first serve basis when ALL registration material is completed COMPLETE registration requires a completed version of this form FOR EACH ATHLETE PARTICIPATING ON TEAM, + $60 registration fee ($60/entire team). WJCCMaccabiLA@westsidejcc.org. Fax: **Please do not forget to sign the form on the back** Athlete 2 Birthdate: Age (as of July 31, 2014): Gender (M/F): Grade: School: T-Shirt Size: Athlete s Cell: Athlete s PARENT INFORMATION Primary contact is: Parent # 1 Parent # 2 Both PARENT #1 PARENT #2 Emergency Contact: Relation: Phone: Doctor s Phone: Insurance Carrier: Policy Holder Plan #: Insurance Carrier Ph. #: Special Needs/Allergies/Medical Issues: Required waiver continued on back 3

5 Athlete 2 Waiver Eligibility I understand that my child must be between in the grade indicated on the front of the registration packet on date of the tournament, and that a school ID may be required to prove eligibility. Fees Total cost of participation in the 3-on-3 tournament is $60/team (or $30/team + 3 NEW pairs of teen/adult-sized jeans). While this can be broken up amongst athletes on the team, to register team will need to submit full $60 in one payment (one check or credit card, or $60 cash). As of Dec.1 registration deadline, this fee is non-refundable. Waiver Parent or guardian agrees to and does hereby indemnify and hold, their individual units, its officers, directors, agents, professional staff, volunteers and its other employees harmless from and against any and all claims, damages, costs, expenses, causes of actions and liabilities for any injury to or death of any person or persons, including the above-mentioned child, himself/herself, or damage to or loss of any property resulting from participation in this program, not withstanding that same may have been caused by any action or inaction, commission or omission, including, but not limited to the negligence of any of the aforesaid or otherwise. Medical Treatment The undersigned parent or guardian certifies that the child is healthy and able to participate in this program at the time of registration. Parent or guardian gives permission to secure proper medical treatment in case of emergency, where parent or guardian cannot be reached. Publicity Parent or guardian permits the use of child s name and/or photographs for publicity, this includes online marketing/publicity (including but not limited to WJCC s website, listserv and Facebook page). I have read the above statement, accept all terms & completed this form to the best of my ability. Parent or Guardian: signature Date: 4

6 3-on-3 Tournament: Hoops For Hope Athlete Registration and Waiver (ATHLETE 3) Completed forms can be ed or faxed to WJCC by Sunday, December 1, Space is limited and all teams will be accepted on first come, first serve basis when ALL registration material is completed COMPLETE registration requires a completed version of this form FOR EACH ATHLETE PARTICIPATING ON TEAM, + $60 registration fee ($60/entire team). WJCCMaccabiLA@westsidejcc.org. Fax: **Please do not forget to sign the form on the back** Athlete 3 Birthdate: Age (as of July 31, 2014): Gender (M/F): Grade: School: T-Shirt Size: Athlete s Cell: Athlete s PARENT INFORMATION Primary contact is: Parent # 1 Parent # 2 Both PARENT #1 PARENT #2 Emergency Contact: Relation: Phone: Doctor s Phone: Insurance Carrier: Policy Holder Plan #: Insurance Carrier Ph. #: Special Needs/Allergies/Medical Issues: Required waiver continued on back 5

7 Athlete 3 Waiver Eligibility I understand that my child must be between in the grade indicated on the front of the registration packet on date of the tournament, and that a school ID may be required to prove eligibility. Fees Total cost of participation in the 3-on-3 tournament is $60/team (or $30/team + 3 NEW pairs of teen/adult-sized jeans). While this can be broken up amongst athletes on the team, to register team will need to submit full $60 in one payment (one check or credit card, or $60 cash). As of Dec.1 registration deadline, this fee is non-refundable. Waiver Parent or guardian agrees to and does hereby indemnify and hold, their individual units, its officers, directors, agents, professional staff, volunteers and its other employees harmless from and against any and all claims, damages, costs, expenses, causes of actions and liabilities for any injury to or death of any person or persons, including the above-mentioned child, himself/herself, or damage to or loss of any property resulting from participation in this program, not withstanding that same may have been caused by any action or inaction, commission or omission, including, but not limited to the negligence of any of the aforesaid or otherwise. Medical Treatment The undersigned parent or guardian certifies that the child is healthy and able to participate in this program at the time of registration. Parent or guardian gives permission to secure proper medical treatment in case of emergency, where parent or guardian cannot be reached. Publicity Parent or guardian permits the use of child s name and/or photographs for publicity, this includes online marketing/publicity (including but not limited to WJCC s website, listserv and Facebook page). I have read the above statement, accept all terms & completed this form to the best of my ability. Parent or Guardian: signature Date: 6

8 Tel: West Olympic Blvd. Fax: Los Angeles, California on-3 Hoops For Hope Basketball Tournament Team Registration Payment Form Team Name Parent Name (or adult responsible for team s payment): Contact Phone Number (re: payment) Total cost for the tournament (select one payment option for team): $60.00/team $30.00/team + 3 pairs of NEW jeans (teenager/adult-size) I would like to make the non-refundable payment indicated above by: Check (made out to Westside JCC, included with this payment form) Cash (included with this payment form) Credit Card (Visa, MC, AmEx, Discover) information listed below Cardholder s name: Type of Credit Card: Credit Card number: Expiration date: Billing Zip: I understand that this payment is non-refundable, and I authorize Westside JCC to charge the above payment to this credit card on the above upon receipt of this form: Cardholder Signature: Parent Signature Date All program fees must be paid in full and are non-refundable. In the event you subsequently cancel your child's participation in the program, under certain limited circumstances Westside JCC may be able to find a substitute to take your child's reserved place in the program. In this event, and at Westside JCC's sole discretion, you may receive a refund of some portion of your program fee, minus any penalty fees, change fees, or other non-refundable costs that we incur on your behalf. The 3-on-3 Hoops for Hope Basketball Tournament is made possible thanks to the generosity of the Jeff Feinberg Foundation.