Mid America Basketball

Waiver Form

Each player must have form completed and signed by guardian. Forms must be presented before player can participate in event. After completion of form please mail to:

Dan Hudson

106 Jameswood Drive

Murray Ky 42071

Participant:

Name___________________________________________________________________

Address_________________________________________________________________

City____________________________________________ State____________________

Sex_____________ Age___________________

InsuranceCompany__________________________________________________________

Group no__________________________________________________________

Camp Participating ___________ Mid America_________ Spring Tip Off

________ Racer Jamboree _________ other

Please read carefully and sign the following. A parent or legal guardian must sign for anyone under the age of 18.

I or my dependent or ward wish to participate in this event, and I absolve Mid America Summer Hoops Inc., its officers, directors, employees, and agents, and anyone else involve directly or indirectly with the event from any liability for injury or illness suffered by me or my dependent(s) in connection with the event. If I or my dependent should suffer any injury or illness as a result of participation in the event, I authorize any of those persons who are conducting or supervising this activity to use their discretion to have me or my dependent transported to and treated at a local medical facility, and I take full responsibility for this action.

I acknowledge that I or my dependent are carried under a health insurance plan, and the information provided above regarding that coverage is current, and if were to change prior to the date of the event, I will notify you prior to participation in the event.

I also approve the use of my picture or that of my dependent taken before, during, or after the event for promotional use.

Date__________

Signature of participant or legal guardian___________________________________