Name *

First Name

Last Name

Participant's Age Range *

8-13 years old

14-18 years old

Parent or Guardian Name *

First Name

Last Name

Emergency Contact *

First Name

Last Name

Has this participant attended Jump & Ball in the past? *

Yes

No

Parental Agreement *

I hereby represent that the athlete has my permission to participate in all Jump and Ball XV games, recreation programs and physical activity programs, which will be taking place Aug. 12 –Aug. 27th, 2023 and is sponsored by LL COOL J Inc., James T. Smith DBA LL COOL J, and The Jump and Ball Foundation. I further represent and warrant that to the best of my knowledge and belief, the athlete is physically and mentally able to participate in Jump and Ball XV. I know of no physical, emotional, or injury related conditions which will be aggravated by or which may affect my child’s ability to participate. In permitting the athlete to participate, I am specifically granting my permission, (both during and anytime after), to Jump and Ball XV to use the athlete’s likeness, name, voice and words in television, radio, film, newspapers, magazines and other media, and in any form, for the purpose of advertising or communicating the purposes and activities of the Jump and Ball XV program and/or applying for funds to support these purposes and activities. If a medical emergency should arise during the athlete’s participation in Jump and Ball XV activities, at a time when I am not personally present so as to be consulted regarding the athlete’s care, I hereby authorize the Jump and Ball XV staff, on my behalf, to take whatever measures are necessary to ensure that the athlete is provided with any emergency medical treatment, including hospitalization, which Jump and Ball XV deems advisable in order to protect the athlete’s health and wellbeing. I hereby authorize the staff of Jump and Ball XV to administer appropriate medical attention to my child in the event of any accident, illness, or injury. I will be responsible for any or all cost of medical coverage and treatment provided, not covered by insurance. I hereby release, hold harmless, discharge and agree not to sue LL COOL J Inc., The Jump and Ball Foundation, James T. Smith DBA LL COOL J, Game Seven Marketing and any of its Directors, Officers, Employees, Coaches, Officials, Volunteers, Agents, Sponsors, Advertisers, Owners / Leasers of Premises and/or The State of New York and/or The City of New York for any and all liability from the athlete’s participation in Jump and Ball XV and any related activities. I am the parent/guardian of the athlete named above. I have read and fully understand the provisions of the above release, and have explained these provisions to the athlete. Through my signature on this release form, I am agreeing to the above provisions on my own behalf and on the behalf of the athlete named above. I hereby give my permission for the athlete named above to participate in Jump and Ball XV.

I hereby give my permission for the athlete named above to participate in Jump and Ball XIII.

Date *

MM

DD

YYYY