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(Sample) Registration Form (Sample)

Dynamite Basketball 2010 Registration Form


The undersigned (“Parent/Guardian”), parent/guardian of _____________________________ (“Camper”) and the Camper signing below and participating in the Dynamite Basketball Camp (“Event”), acknowledge that participation in the Event exposes Camper to a possible risk of personal injury. We represent that Camper is physically fit to participate in strenuous athletic activity and hereby release Harvest Outreach Ministries Inc. operating as Dynamite Basketball and their respective officers, directors, employees, agents, licensees, subsidiaries, consultants, independent contractors and affiliates, from any and all liability from personal injuries, recurrence of any disclosed or undisclosed pre-existing injury or illness, property damage or other claims arising from or in connection with Camper’s participation in the Event, including claims that are known and unknown, foreseen and unforeseen, future or contingent.


We, Parent/Guardian and Camper, covenant that we will not now or at any time in the future, directly or indirectly, commence or prosecute any action, suit or other proceeding against the Company and its officers, directors, employees, agents, licensees, subsidiaries, consultants, independent contractors and affiliates, arising out of or relating to the actions, causes of action, claims and demands hereby waived, released or discharged by me.

For good and adequate consideration, which we, Parent/Guardian and Camper, acknowledge has been received, individually and collectively, hereby grant, release, and quitclaim to the Company the right and authority to use, sell, reproduce, and distribute, quoted material, biographical information, Camper’s photograph, likeness, recorded voice or videotaped/filmed appearances obtained in connection with the Event (the “Materials”) for promotional and advertising purposes or programs as the Company in its sole discretion will deem appropriate.

Parent/Guardian also represents, warrants and agrees that Parent/Guardian is entitled to the care and custody of Camper and is Camper’s legal guardian; that during the minority of Camper and for a reasonable time afterwards, Parent/Guardian will use all reasonable efforts to prevent Camper from attempting to or actually disaffirming the agreements the subject of this Form; that Parent/Guardian hereby acknowledges that Parent/Guardian has read the Form and is satisfied that it is fair and equitable for the benefit of Subject; and that Parent/Guardian will not revoke this consent, approval and authorization.


Date: ________________


Parent/Guardian Printed Name: ___________________________


Address: ___________________________________________________


Parent/Guardian Signature: ___________________________  Relationship to Camper: _____________________


Camper Printed Name: ___________________________


Camper Signature: ___________________________


Dynamite Official Signature_______________________________ (Use by Dynamite Staff Only)


Facility Director (responsible party for venue and persons) Signature ____________________________________

Last Modified: June 30, 2010

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