Players Name:

Address:

City, State & ZIP:

AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Player's E-Mail:

Parent's E-Mail:

Contact Number:

Grade Entering Fall '08:

School/Coach Name:

Tell us about what
skills and parts of your
game you would like
to work on:

Parent/Legal Guardian:

Today's Date:

By checking this box as the parent of, I herby acknowledge and agree to release Bound 4 Glory, Duez Henderson, Jason Price, all gym facilities, all sponsors, employees, medical trainers and consultants, fully harmless from any injury, claim, legal fees, or damage which may occur to my child as a participating member of Bound 4 Glory Basketball Training.

I acknowledge that I have read this hold harmless/release of liability form and I fully understand the contents. I give my child permission to participate in the Bound 4 Glory Basketball Complete Player Clinic.

Emergency Contact:

Emergency Phone:

Insurance Company:

Insurance Number:

Any Known Medical
Conditions/Allergies?

Yes No

If yes, please explain:

Parent/Legal Guardian:

Today's Date:

In the case of accident or illness , I herby give permission that my child be given emergency treatment.

In the event I cannot be contacted,I further authorize and consent to the administration of any and all medical, dental, and surgical examinations or operation and treatment or all related care that may be ordered at the physician and or dentist in attendance at the medical center deemed necessary for emergency treatment. I herby consent to the release of medical reports to any doctor, dentist, or agency and consent to the admission of the above named minor person to the hospital.

*All fields are required.