Athlete Registration Form: Please fill up the following required information: Requested program (please choose from the below drop down menu): * Boys and Girls ages 5-6Boys and Girls ages 7-9Boys ages 10-13Girls ages 10-13Boys ages 13-16Girls ages 13-16Christmas Break Camp 2011 - 2012Passover Break Camp 2012March Break Camp 2012End of School Year Camp 2012Summer Camp 2012End of Summer Camp 2012 Preferable time:* Monday-Friday - 17:30-18:45Saturday anytimeSunday anytime Athlete Information: Athlete First Name:* Athlete Last Name:* Athlete Date of Birth:* Athlete Gender:* MaleFemale Athlete Mailing Address: Address A:* Address B: City:* Province/State:* Postal/Zip Code:* Country:* Home Phone:* Cell Phone: First Parent or Guardian: Please provide contact details below for the first parent or guardian living at the SAME address as above Parent A First Name:* Parent A Last Name:* Parent A Day Time Phone:* Parent A Cell Phone / Pager:* Parent A Email Address:* Second Parent or Guardian: If applicable, please provide contact details below for the second parent or guardian Parent B First Name: Parent B Last Name: Parent B Day Time Phone: Parent B Cell Phone / Pager: Parent B Email Address: Emergency Contact Information: In the case of an emergency, we will first attempt to contact the parents/guardians. If they cannot be reached, we will contact the below authorized emergency contacts First Contact: Contact A First Name:* Contact A Last Name:* Contact A Relationship to Athlete:* Contact A Day Time Phone:* Contact A Cell Phone / Pager:* Second Contact: Contact B First Name: Contact B Last Name: Contact B Relationship to Athlete: Contact B Day Time Phone: Contact B Cell Phone / Pager: Medical and Activity Information: Health Card Number:* Athlete Physician's Name:* Physician's Phone Number:* Are there any medical or behavioural problems our staff should be aware of? (Example: epilepsy, diabetes, allergies, drug reactions, disabilities, ADD, previous injuries, asthma, medications, etc.) If Yes, please explain below A: Yes No Explanation A: Does the Athlete have any allergies? If Yes, please explain below B: Yes No Explanation B: Is the athlete under any form of treatment/medications for any illness, condition or injury? If Yes, please explain below C: Yes No Explanation C: Please list all medications the athlete is currently taking due to the above conditions. Will the athlete require the medication during our Academy activities (camp, weekly lessons)? If not applicable write N/A Explanation D: Please list specific activities to be encouraged or limited: Explanation E: Medical Authorization Form: To the best of my knowledge this child is in good health and is physically able to participate in all MG BasketBall Academy activities, except as previously indicated. I will notify MG BasketBall Academy if there is any change. Parent Signature (Please type Parent or Guardian full name A):* Date A:* Consent, Release and Indemnity Form: This form MUST BE COMPLETED BY the ATHLETE's Parent(s)/guardian(s) BEFORE REGISTRATION CAN BE CONFIRMED. THE parent/guardian who PROVIDES CARE for and has a right to make decisions about the ATHLETE must sign this form. IMPORTANT NOTICE: BY SIGNING THIS FORM YOU ARE ACCEPTING RISKS AND AGREEING TO GIVE UP CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE. DO NOT SIGN THIS FORM UNTIL YOU HAVE READ IT, COMPLETELY UNDERSTAND IT, AND AGREE TO ALL OF ITS TERMS. I/We, the undersigned parents/legal guardians of the Athlete hereby acknowledge that we have been offered to have the Athlete participate in a program operated by MG Sports Management INC and HoopDome that manage MG BasketBall Academy (the "program"). I/We understand that in this Form, the "Academy" includes MG BasketBall Academy, its employees, officers, directors, partners, mandataries, representatives, agents, subsidiaries, parent or affiliate corporations, successors, assigns, and any volunteers. I/We also understand that participation in the Program involves the Athlete`s use of facilities and equipment at the Program, and the Athlete`s participation in the activities offered at the Program. ACTIVITIES: The activities at the Program may include, but are not necessarily limited to: Playing competitive basketball Low and high energy recreational activities RISKS: The Athlete`s participation in the Program involves a risk of injury or death and/or damage to or loss of property. Athletes and/or their parents/guardians must assume these RISKS. All of the RISKS cannot be listed on this Form, but may include: The Athlete`s participation in the Program may lead to minor or serious bodily injury. Participating in the Program may also lead to an impairment of the Athlete`s future ability to study, work and earn a living; to engage in other business, social, personal, intimate and recreational activities; and generally to enjoy life. The Athlete`s participation in the Program may lead to Other Risks. Other Risks may include those associated with the possible conduct of other participants, whether it is negligent or intentional; and the contraction of a contagious illness or communicable disease. The Athlete`s participation in the Program may lead to additional risks not described above. PARENT/GUARDIAN CONSENT: I/We consent to the Athlete`s participation in the Program with the knowledge of the RISKS involved. ACCEPTANCE OF RISK: I/We accept any and all RISKS, including the risk of injury or death and/or damage to or loss of property associated with the Athlete`s participation in the Program. WAIVER, AGREEMENT NOT TO SUE AND INDEMNITY: In exchange for the Athlete`s participation in the Program, I/we AGREE TO THE FOLLOWING: a. I/We agree to waive any and all liability, of any kind, of the Academy; b. I/We agree that I/we will not commence or participate in any type of claim or lawsuit against the Academy; and c. I/We agree that I/we will completely indemnify and hold harmless the Academy for any claims or lawsuits against the Academy by any person or corporation in any way associated with the Athlete`s participation in the Program, including any claims or lawsuits against the Academy by the Athlete in his or her personal capacity or by any legal person on his or her behalf. I/We understand that by signing below, I am/we are acknowledging our AGREEMENT TO THE ABOVE. EXPULSION: I/We agree that any violation of the rules of the Academy or the Program by the Athlete or any behaviour or health status that puts the Athlete or others at physical or emotional risk will result in immediate dismissal from the Academy activity at the discretion of the Academy management. CONTAGIOUS ILLNESS AND EMERGENCY AUTHORIZATION: To the best of my/our knowledge, the Athlete does not have a contagious illness and is physically able to participate in all Program activities. If the Athlete comes in contact with a communicable disease at any time prior to the Program start date, or has any change in his/her health condition, I/we will inform the Academy immediately. All medical issues requiring ongoing medical supervision or care have been fully noted on the ATHLETE REGISTRATION FORM. I/We give permission for any and all health/personal care information to be shared with the appropriate Academy staff and outside medical personnel as necessary. I/We give permission to the Academy Directors or their delegate(s) to administer over the counter or prescription medications and provide routine health care to the Athlete as directed by a physician. I/We agree that if I/we cannot be reached in the event of an emergency, the physician selected by the Academy staff may secure proper treatment for the Athlete, including, without limitation, hospitalization, medications, anaesthesia, surgery or blood transfusion and at my/our expense. JURISDICTION, APPLICABLE LAW AND CLASS ACTION WAIVER: I/We agree that any dispute arising out of, in connection with or incident to the Athlete`s participation in the Program shall be litigated, if at all, before the Superior Court of Ontario located in Toronto, Ontario, to the exclusion of the courts of any other city, province or country. I/We further agree that the applicable law to be applied to any dispute shall be the law of the Province of Ontario, with the exception of its conflict of laws rules. I/We understand that this Form provides for the exclusive resolution of disputes through individual legal action on my/our own behalf instead of through any class action. Even if the applicable law provides otherwise, I/we agree that any lawsuit against the Academy whatsoever shall be litigated by me/us individually and not as a member of any class or as part of a class action, and I/we expressly agree to waive any law entitling me / us to participate in a class action. SEVERABILITY: If any provision of this Form is held by a Court to be unenforceable, then such provision will be modified to reflect the parties` intention. All remaining provisions of this Form shall remain in full force and effect as drafted. The PARENT/GUARDIAN WHO PROVIDES CARE FOR AND HAS A RIGHT TO MAKE DECISIONS ABOUT THE ATHLETE MUST SIGN THIS FORM. WEEKLY LESSON REFUND POLICY: No make-up class or credit will be available to a student who misses a clinic. Should an athlete miss more than 5 clinics due to medical reasons (accompanied by a doctors note) a credit will be issued for those lessons. No cash or cheque will be issued. There are no refunds for weekly lessons. We must receive cancellations request in writing, there will be a cancellation fee of $50.00, and we will only give credits on the remaining lessons, athlete`s account. credits will only be give from the date that we receive the request for cancellation. CAMP REFUND POLICY: Cancellation, in writing, for each registered player, received 2 months prior to the camp session will receive a refund minus a cancellation fee of $50.00. There can be no refund of fees paid within 2 months prior to camp. Days missed for any reason cannot be refunded; however, in case of illness for three consecutive days or more, a written request accompanied by a Doctor`s certificate is required. In this situation, a 50% refund will be made for the days missed. Pro-rated refunds/credits and/ or make-up days or partial days are not available for days absent or as a result of services not being fully utilized or should the Camp be unable to operate in whole or in part for any reason whatsoever. Switching Fee: There will be a 25 dollar fee for switching program dates for each occurrence. PUBLICITY: consent(s) to the use by MG BasketBall Academy of each athlete`s likeness for publicity/promotional purposes. LUNCH and SNACK: Parents agree to provide their children with daily lunch, drink, snacks (that do not contain nuts of any kind) and all prescription medications (including epi-pens) where necessary, as well as all relevant supplies that pertain to such medications (i.e. carrying pouch etc.) If this form is signed by two parents/guardians, such parents/guardian assume full responsibility for payment and acknowledge that they have read and understood all MG BasketballBall Academy policies and MG BasketBall Academy can rely on all representation information given. If only one parent/ guardian signs this form, MG BasketBall Academy may fully rely on his/her authority in connection with all such matters. I understand that from time to time MG BasketballBall Academy may use personal information contained in this form for the purpose of mailing and emailing MG BasketBall Academy brochures, programs and newsletters. By checking this box, I consent to the use of the personal information contained on this form for that purpose: Yes, I Consent In the space provided below, indicate your acknowledgment and acceptance of the entire content of the preceding text by printing AND signing where indicated: I have read the above and I agree Parent Signature (Please type Parent or Guardian full name B):* Date B: Please enter the phrase as it is shown in the box above.