Jimmy Yagi Summer Hoops Camp Returns to Hilo July 26-29, 2016 (Flyer and Registration Forms)

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COUNTY OF HAWAI' I DEPARTMENT OF PARKS AND RECREATION REGISTRATION FORM / CONSENT / RELEASE OF CLAIMS Date Form Filled Out 20 DISTRICT: Hilo ACTIVITY: 4th ANNUAL JIMMY YAGI SUMMER HOOPS BASKETBALL CAMP (July 26-29, 2016) FACILITY: Ages 9-12, 9 AM -3 PM Panaewa Covered Courts & Ages 13-17, 9 AM -4 PM Afook Chinen Civic Auditorium *AII ages must show up at the Afook Chinen Civic Auditorium on the first day of camp Tuesday, July 26th at 8:OOAM to register & take camp photo. * Please bring water, lunch and/or snack. PLEASE CHECK T-SHIRT SIZE: YOUTH SM M L ADULT SM M L XL PARTICIPANT'S NAME GENERAL INFORMATION (Please Print) (Last) (First) (MI) AGE BIRTHDATE PARENT/LEGAL GUARDIAN PHONE (home) MAILING ADDRESS E-MAIL SCHOOL (Last) (First) (MI) PHONE (work) PHONE (cell) GRADE HEALTH & EMERGENCY INFORMATION PLEASE LET US KNOW ANY MEDICAL INFORMATION RELEVANT TO THE CARE OF YOUR CHILD: CHILD'S DOCTOR PHONE HEALTH PLAN EMERGENCY CONTACTS other than parent/guardian listed above: NAME PHONE RELATIONSHIP NAME PHONE RELATIONSHIP k‘.1We are committed to making our recreation programs accessible. Does your child need modifications due to a disability to effectively participate in our program? Please Check One: YES NO If yes, please complete a Modification Request with our Recreation Specialist, ph. 961-8681. Adult attendants or skills trainers who accompany a child in our P&R programs must register before the first day of the program. MEDIA RELEASE I/We hereby give permission to the Department of Parks & Recreation, County of Hawaii, to allow the news media to film and photograph program activities provided: 1) They are for news and non-commercial purposes; 2) The program director determines the filming, etc., will not unduly interfere with or disturb the programs; and 3) Individual children are not singled out for demonstrating photography or interview purposes against their wishes. Please Check One: YES, permission granted NO, permission denied (If no box is checked, assumption is "No, permission denied") CONSENT In consideration of the permission granted to me by the County of Hawaii, State of Hawaii, for my minor child ("Child") to participate in the above-mentioned sport/activity ("Activity"), the above-named PARENT/LEGAL GUARDIAN ("Parent") consents and agrees that: a. Child is allowed to actively participate in Activity; b. Child is participating voluntarily, and with Parent's approval and consent. c. Child is in reasonably good physical and mental health, such that Minor can safely participate in Activity. d. Parent recognizes and understands that participation in the Activity involves risk of death, personal injury and/or property damages, commonly inherent in such Activity. e. Parent shall notify a representative from the Department of Parks and Recreation if there is any change in Child's physical and/or mental condition such that MINOR cannot safely participate in Activity. f. The Department of Parks & Recreation may refer Child, if injured or ill, to my family doctor when I cannot be reached. When there is no family doctor, the Department has the discretion to select a doctor. I also agree: 1. 1 have read BOTH SIDES of this registration form, including the Informed Consent, Assumption of Risks, Code of Conduct, and Release of Claims on the back side of this page. 2. 1 understand and agree with all of its terms. 3. 1 have filled out the information on this form fully and completely. 4. 1 will notify the County immediately in writing of any changes to the information above. 5. 1 am signing this form voluntarily and with full knowledge of its significance. IN WITNESS WHEREOF, I have executed this Registration, Consent and Assumption of Risks, Release of Claims and Indemnification and Code of Conduct at on the day and year first written above. (Place of Execution) Signature of Witness (Age 18 or Older) Signature of Parent or Legal Guardian Printed Name of Witness Phone Number Address Rev 5/23-06, 8/12 City Zip Code Possession or consumption of alcohol by persons under 21 is prohibited. County of Hawai'i is an Equal Opportunity Provider and Employer