DUNK BASKETBALL CAMP PARTICIPANT MEDICAL INFORMATION & RELEASE FORM

The following waiver and release form must be completed in order to participate in any Dunk Basketball  camp or training.

1. I hereby give permission to the medical personnel selected by the Dunk Basketball and its adult staff to arrange for emergency medical treatment, order X-rays, routine tests, to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event I am unable to make decisions in an emergency, I hereby give permission to the physician selected by Dunk Basketball and its adult staff to secure and administer treatment, including hospitalization, for the child named below.

2. I authorize approved staff members to transport my child in a personal vehicle in case of a medical emergency.

Child's Name _____________________________________________________________________

Age____________  Birth Date ___________ Grade _________

Parent's Name ___________________________________ Home Phone _______________________________

Primary Address ________________________________________________________________________

Cell Phone___________________________  Home Phone _______________________________

Emergency Contact ________________________________________________________

Relationship __________________________

Home Phone ____________________________ Cell Phone _________________________________________

Physician's Name ______________________________________ Physician's Phone #_______________

Health Insurance Company ______________________________ Group Policy # ______________________________

Name of Policyholder _________________________________ Insurance Co. Telephone ________________________

Please list all allergies, including medicines, foods, and insect’s ____________________________________________________________

Is your child currently taking medicine for an existing medical condition (i.e., asthma medication) Y N

Please list ______________________________________________________________________________________________

Parent's Signature _________________________________________ Date __________________

YOUTH PARTICIPANT WAIVER AND RELEASE OF LIABILITY

In consideration of my child, __________________________________________________, being allowed to participate in sports, dance and/or other programs with Dunk Basketball, the undersigned acknowledges and agrees that:

Participation in, sports, dance and/or other activities can result in physical injuries. While particular rules, equipment and personal discipline may reduce such risks, the risk of injury, including serious injury and disability, does exist.

The undersigned, knowingly and freely assumes all such risks, both known and unknown, and assumes full responsibility for the participation of the minor child noted above. The undersigned, on his or her behalf, on behalf of the child noted above, and behalf of all heirs, assigns, personal representatives, and next of kin, hereby releases and holds harmless, to the extent permitted by law, Dunk Basketball, its officers, officials, agents and/or employees, its sponsors, and other participants and their families with respect to any and all injury, disability, death, loss, or damages to person or property.

I have read this release of liability and assumption of risk agreement, fully understand its terms, and sign it freely and voluntarily without any inducement.

Parent/Guardian Signature _________________________ Date __________ Print Name ______________________

The above waiver and release forms are valid for the current season, which begins August 2008 and ends August 2009