CITY SLAM 2010

REGISTRATION FORM

Team Name: ______________________________

Player’s names: 1. __________________________ Age: ____

2. __________________________ Age: ____

3. __________________________ Age: ____

4. __________________________ Age: ____

Please name one player from your team who will be participating in the skills
competition: Player’s name_________________________

(Each player is required to fill out a waiver form in order to participate in the
tournament.)

*Please keep in mind that all teams are required to check-in between
9:00a.m-9:30a.m to ensure that they receive their tournament jersey and are
placed in the bracket.

Method of Payment:(Please check one)

Cash___ Check___ Debit Card___

*Make all checks payable to New Hope International

*All forms of payment must be received by October 2, 2010 in

order to participate. Payment can be brought to New Hope
International or pay online at MyNHI.org
 Waiver Release Form
Participant Information:

Name _________________________________________________________________________
Age ___________ Grade ____________ School _________________________Sex: M or F
Home Address ______________________________________________________Neighborhood___________________
City _______________________________ State ______Zip Code _____________Birth date ______________________
Email Address______________________________________________________________________________________
Home Phone # ________________________________________Cell Phone # __________________________________

Guardian Information (For Participants Under 18):

Mother’s Name __________________________________________________Cell Phone # _______________________

Work Phone # _____________________________ Email Address ____________________________________________

Father’s Name __________________________________________________Cell Phone # _______________________

Work Phone # _____________________________ Email Address ____________________________________________

Emergency Information:

Family Physician ________________________________________________Phone # ____________________________

Insurance Company ______________________________________________Policy # ____________________________

Emergency Contact _________________________________________________________________________________

Relationship _________________________________Phone # _______________________________________________

AGREEMENT:
I have read and fully understand the above information on Policies and Procedures.
Assumption of Risk & Waiver of Liability:

As the legal guardian of ________________________, I recognize the possibility of injury ranging from minor injury to terminality while participating in
activities and events with Kingdom Impact/ New Hope International (KI/ NHI) that include, but are not limited to cheerleading, tumbling, dance,
basketball, open gym, etc. With the knowledge of these possible risks, I grant permission for participation by the aforesaid in KI activities and events. I,
my administrators, executors, and/or other representatives vow to waive and release all liability for any and all damages/injuries endured by the
aforesaid while under the instruction or supervision of KI/ NHI and/or its representatives, including but not limited to transportation to and from KI/ NHI
activities and events.

I recognize that KI/ NHI staff and representatives are not certified medical practitioners of any kind. With this knowledge, I authorize basic first aid
treatment by KI/ NHI staff and representatives to the aforesaid in the event of illness or injury. If deemed necessary by KI/ NHI staff or representatives, I
give permission for the aforesaid to be transported to any health care facility or hospital by a KI/ NHI staff member or representative or via an
ambulance. I release the physician to administer x-rays, perform exams, and/or medical/surgical diagnosis in the event of an emergency. I confirm that
the aforesaid is currently covered by medical insurance, that he/she will continually have coverage throughout the duration of participation with KI/ NHI,
and that I personally, or through my health insurance agency, will provide payment for these expenses and for those expenses incurred in the future as
a result of the injury endured while under KI/ NHI instruction or supervision.

As the responsible guardian, I will inform the aforesaid of the possibility of injury associated with participation with KI/NHI, encourage following all Safety
Rules, and stress the importance of following instruction of KI/NHI staff so as to decrease the risk of injury.

Signature of Guardian ________________________________________________________ Date ________________

Signature of Participant _______________________________________________________ Date ________________