Athletics & Academics Basketball Camps

Camp Participant Registration

Camp Date/Location

Participant Name

Parent's Name

Address

City / Zip

Phone

Age / School

T-shirt Size

CAMP PARTICIPANTS RELEASE AND WAIVER

I hereby forever release and discharge Adonal Foyle, Adonal Foyle Enterprises, LLC, Kerosene Lamp Foundation Inc., Athletics & Academic LLC, and their respective agents, affiliates, officers, directors, managers, employees, members, partners, shareholders and representatives from and against any and all liabilities, claims, demands or causes of action for any injury, illness, incident or damage (physical or otherwise) suffered by my child arising out of, or related to, my child's participation in the Adonal Foyle "Athletics and Academics" basketball camp (the "camp"), including, without limitation, my child's travel to and from the camp.

I hereby represent, warrant and covenant that I have no knowledge of any physical or mental impairment that would affect my child's participation in the camp.

Further, I hereby authorize the camp's staff to act in accordance with their best judgment in any emergency requiring medical attention.

Insurance Company

Policy Holder

PPO/PPN/HMO/EPO

Policy #

Group #

Physician's Name

Physician's Phone

Allergies

Medication/Dosages