EEK FITNESS, INC.
P.O. BOX 185 SAN JACINTO CA, 92581
2012 BASKETBALL REGISTRATION AND CONSENT WAIVER
FORM FOR PROGRAM FEBRUARY AND MARCH 2012
PLEASE PRINT
NAME: _____________________________________________________________________
STREET ADDRESS: __________________________________________________________
CITY: _________________________________________
ZIP CODE: ________________
DATE OF BIRTH: ________________
HEIGHT: _______
SEX: _______
DISABILITY___________________________________________________________
PARENT NAME (S): ________________________________________________________
HOME PHONE #: _________________ ______
WORK PHONE#:_____________________
E -MAIL ADDRESS__________________________________________________
AS THE PARENT, LEGAL GUARDIAN OF THE CHILD NAMED ABOVE, OR MYSELF, IF OVER 18, I
HEREBY GIVE MY CONSENT AND APPROVAL FOR MY CHILD/MYSELF TO PARTICIPATE AS A
TEAM MEMBER IN EEK'S BASKETBALL PROGRAM. I UNDERSTAND THAT THERE ARE CERTAIN
RISKS OF INJURY INHERENT IN THE PRACTICE AND PLAY OF THIS SPORT, AS WELL AS THE
TRAVEL AND OTHER RELATED ACTIVITIES INCIDENTIAL TO MY CHILD’S PARTICIPATION AND
I AM WILLING TO ASSUME THESE RISKS ON BEHALF OF MY CHILD.I HEREBY CERTIFY THAT
MY CHILD IS HEALTHY AND HAS NO PHYSICAL OR MENTAL DISABILITIES THAT WOULD
RESTRICT FULL PARTICIPATION IN THESE ACTIVITIES, EXCEPT AS LISTED ABOVE. IN
ADDITION TO GIVING MY FULL CONSENT FOR MY CHILD’S PARTICIPATION, I HEREBY WAIVE
AND RELEASE AND HOLD HARMLESS EEK FITNESS INC, ITS OFFICERS AND DIRECTORS,
COACHES, REFEREES, VOLUNTEERS, SPONSORS, SUPERVISORS, AND REPRESENTATIVES, FOR
ANY INJURY THAT MAY BE SUFFERED BY MY CHILD/MYSELF IN THE NORMAL COURSE OF
PARTICIPATION IN THE DESIGNATED SPORT, AND THE ACTIVITIES INCIDENTIAL THERETO,
WHETHER THE RESULT OF NEGLIGENCE OR ANY OTHER CAUSE.
_________________________________________ _______________
SIGNATURE DATE
CONTACT US: 951-375-6906 (Erica) eekfitness@yahoo.com
eekandfriends.com
EEK FITNESS, INC.
A PUBLIC NONPROFIT ORGANIZATION WHICH EXISTS FOR THE BENEFIT OF
INDIVIDUALS WITH DISABILITIES AND THEIR FAMILIES.
.
START DATES
PROGRAM WILL BE FROM February 4th through March 31st
COST: $35 per player.
Price includes team shirt and individual and group photo.
LOCATION:
Winchester Valley Wide
32665 Haddock Street
Winchester, CA 92596
(951) 926-5917