Basketball Yukon

INFORMED CONSENT, RISK ACKNOWLEDGEMENT AND INDEMNITY AGREEMENT

WARNING: By signing this document you indicate that you understand the risks associated with this activity, you are aware that by allowing your child to participate in the activity you are exposing him / her to the risks identified below. It gives Basketball Yukon the authority to secure medical assistance for your child for which you agree to be financially responsible. You are agreeing to assume financial responsibility for any damage to third persons or their property cause by your child.

PLEASE READ CAREFULLY!

TO: BASKETBALL YUKON

CHILD’S NAME: _____________________________________________

PARENTS/GUARDIANS NAME: _________________________________________________________

ADDRESS OF GUARDIAN/ PARENT: _____________________________________________

_____________________________________________________________________________

1. I am aware that by allowing my child to participate in the ______________________________, I will be exposing him / her to the following inherent risks, including but not limited to:

GENERAL:

- theft, vandalism or loss of personal property;

- any manner of injury resulting from use, misuse, or failure of equipment;

BASKETBALL

- impact with obstructions, other participants, referees or spectators, game or training equipment (which may include balls or other apparatus), visible or non-visible;

- potential for bone and muscular skeletal injury, such as sprains and strains;

- episodes of light headedness, fainting, chest discomfort, leg cramps and nausea;

- an increased load on the heart, which may result in dizziness, shortness of breath and in extreme circumstances, may result in a heart attack.

I have explained the risks associate with this activity to my child and she understands the risks.

2. Basketball Yukon may secure such medical advice and services as it, in its sole discretion, may deem necessary for my child’s health and safety and I shall be financially responsible for such advice and services.

3. I understand that it is my child’s responsibility to abide by the rules and regulations imposed on the participants by the instructor.

4. I agree to HOLD HARMLESS AND INDEMNIFY Basketball Yukon from any and all liability for any damages to the property of, or personal injury to, any third party resulting from my child’s participation in this activity.

I HAVE READ AND UNDERSTOOD THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS AGREEMENT I AM ACCEPTING FINANCIAL RESPONSIBILITY FOR ANY MEDICAL ASSISTANCE BASKETBALL YUKON MAY DEEM NECESSARY FOR MY CHILD’S HEALTH AND SAFETY AND ALSO FOR ANY DAMAGE TO THIRD PERSONS OR THEIR PROPERTY THAT MY CHILD MAY CAUSE.

Signed this ____day of ___________, 2007

Signature of Parent/Guardian __________________________________

Witness Signature _____________________________

Witness Name (please print) _________________________

Witness Address ________________________________________ Witness Telephone # _____________

This informed consent must be completed in full, signed, dated, and witnessed before your child is allowed to participate in the activity.