Youth Skills Clinic

Athlete Information

Name *

Gender *

Date of Birth *

School *

Parent/Guardian Information

Name *

Email Address *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Relationship to Athlete *

Phone Number *

Medical Information

Special Needs/Concerns *

Current Medications *

Known Allergies *

Primary Care Name & Contact

Consent & Agreement

Checkboxes *

I, the undersigned, am the parent/guardian of the participant named below. I hereby give my consent for my child to participate in the Back to Basics Basketball Camp organized by Momentum Youth Sports Training. I acknowledge that participation in the basketball activities involves inherent risks, including but not limited to injury, and I assume all risks associated with my child’s participation. I release and hold harmless Momentum Youth Sports Training, its coaches, staff, volunteers, and any affiliated entities from any and all claims, liabilities, or damages arising from my child’s participation in the camp. In case of illness or accident, I authorize emergency treatment by qualified medical personnel and permit the person in charge to take my child to seek necessary medical care. I consent to the facility securing all required emergency medical care for my child. By signing, I confirm that I have read and understood this consent and liability waiver.

Layout Information Allergies

Signature *

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Date *