May 15, 2021

Please describe any disabilities, health concerns, special diets, allergies, and all medical conditions.

Please include special medication information.

I represent and warrant that to the best of my knowledge and belief I am/my child is physically and mentally able to participate in Special Hoop Camp. I also represent that a licensed examiner has reviewed the health information set forth in my/the participant’s application and has certified, based on an independent medical examination, that there is no medical evidence which would preclude my/the participant’s participation. Special Hoop Camp has my permission (both during and any time after) to use my/the participant’s likeness, name, voice, or words in either television, radio, film, newspapers, magazines and other media in any form for the purpose of advertising or communicating the purposes and activities of Special Hoop Camp and/or applying for funds to support these purposes and activities. If a medical emergency should arise during my/participant’s participation in Special Hoop Camp activities at a time when I am not personally able/present to be consulted regarding my/participant’s care, I authorize Special Hoop Camp to take whatever measures are necessary to protect my/participant’s health and wellbeing, including, if necessary, hospitalization. I, the undersigned, have read and fully understand the provisions of the above release, and if I am an adult athlete someone has explained these provisions to me. By signing this release form I agree to the above provisions. If I am the parent/guardian of the athlete named on this form I am agreeing to the above provisions on my own behalf and on behalf of the athlete named on this application. If I am a witness for an adult athlete I certify that I have reviewed this release with the athlete and am satisfied that the athlete understands this release and has agreed to its terms.