Parents Name First Last Player's Name First Last Date of Birth MM slash DD slash YYYY Phone NumberEmail(Required) Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact Person First Last Emergency Person Phone NumberRelease & Agreement LEGAL AGREEMENT Jaxx City Elite INC Basketball Program (Assumption of Risks, Release of Liability, Waiver of Claims, and Indemnity Agreement) BY SIGNING THIS DOCUMENT, YOU WILL GIVE UP LEGAL RIGHTS, WHICH INCLUDING THE RIGHTTO SUE. PLEASE TAKE YOUR TIME AND READ CAREFULLY 1. This is a legal agreement between players or Parent /Legal Guardian of player(s) of players of Jaxx City Elite INC (“Jaxx City Elite”) and Jaxx City Elite INC. basketball program. 2. By signing this agreement, I confirm that I am the child’s parent or legal guardian, or that I otherwise have legal authority to sign this agreement on behalf of the child. ____ 3. By enrolling my child in the basketball Program, I acknowledge that I my child is fit to engage in this physical activity. I understand and accept ALL risks, which includes the possibility of but not limited to, physical and emotional injury, cuts and bruises, muscle and joint sprains, strains, and broken bones. I, _________________________ ,VOLUNTARILY ACCEPT AND ASSUME ALL OF THE RISKS ASSOCIATED WITH Jaxx City Elite BASKETBALL ACTIVITIES AND I CHOOSE TO PARTICIPATE DESPITE THE RISKS._________________________ 4. I accept full responsibility of any lost, stolen, and or damage personal items and will not hold Jaxx City Elite, their employees, and volunteers accountable. _________________________ 5. Jaxx City Elite employees seek to create a safe environment, but are unable to eliminate all of the risks associated with the sport of basketball. I understand it is not possible to eliminate many of the risks associated with the sport of basketball without jeopardizing the essential qualities of the activity. I,____________________________, understand and accept ALL of the risks associated with Jaxx City Elite basketball activities, which includes but not limited to, physical or emotional injury._________________________ 6. By signing this agreement on behalf of my child, I confirm that I have assessed the risks associated with Jaxx City Elite basketball activities and I VOLUNTARILY ALLOW MY CHILD TO PARTICIPATE in Jaxx City Elite Basketball Program despite the risks. I will accept ALL responsibility and liability for any injury incurred during the hours that my child is involved in the Jaxx City Elite Program. _________________________ 7. I confirm that I have read and understand the rules governing my child’s participation in Jaxx City Elite Basketball program. I understand that Jaxx City Elite rules have been implemented for the safety of all participants, and I have explained the rules to my child. I understand that my child’s failure to follow Jaxx City Elite rules could result in physical and financial damages, injury, or death._________________________ 8. I acknowledge that my child’s failure to follow the rules could result in EXPULSION from Jaxx City Elite. _____ 9. I agree to GIVE UP MY RIGHT TO SUE Jaxx City Elite OR ANY OF ITS EMPLOYEES DUE TO ANY CAUSE WHATSOEVER, including Jaxx City Elite negligence. breach of the Occupiers’ Liability Act, R.S.O. 1990, c. O.2. for any damages, physical or emotional injury, or death that I, or my family, or estate may suffer as a result of my child’s participation in Jaxx City Elite Basketball Program. I, ________________, agree to waive ANY AND ALL claims that I have or may have in the future against Jaxx City Elite. ____ 10. I also agree to hold harmless and indemnify Jaxx City Elite from any and all liability for any damages, physical and emotional injury, or death caused to any third party as a result of my or my child’s participation in Jaxx City Elite basketball program._________________________ 11. I agree that if any portion of this agreement is found to be void, unenforceable, or inapplicable, the remaining portions shall remain in full force and effect. _____ 12. I confirm that have had sufficient opportunity to read this entire agreement, have understood the terms of this agreement and AGREE TO BE BOUND by the terms of this agreement. _________________________ 13. I have been given the opportunity to ask questions about this agreement and are satisfied with the answers I have received concerning the questions that I have asked. _________________________ 14. All Payments made to Jaxx City Elite are non-refundable and non-transferable. Parent/Legal Guardian/Power of Attorney Name _______________________ Minor Participant(s) Full Name: ________________________________________ Minor Participant(s) Birth Date: _________________________________________ Signature: ______________________________________________ Date:______________________________________________ PLEASE E-TRANSFER $125 TO COMPLETE REGISTRATIONJaxxcityelite@Gmail.Com
