Please PRINT, FILL OUT and RETURN the Form below

NAME: _____________________________________

DATE OF BIRTH: ___________________________

ADDRESS: _________________________________

CITY: ______________________________________

STATE: ________________

 ZIP: ________________

(H) PHONE #: ________________

(C) PHONE #: ________________

MOTHER’S NAME: _________________________

FATHER’S NAME: __________________________

EMERGENCY CONTACT NAME: __________________________

PHONE #: ________________

Participating in any sport requires an acceptance of risk of injury. ZMT Cerebral LLC as taken reasonable precautions to minimize the risk of significant injury by providing competent coaching, well maintained facilities and proper conditioning. The chances of an athlete sustaining a catastrophic sports injury are extremely remote, yet understand that serious injuries can happen to anyone. With this understanding, the undersigned does hereby waive and release ZMT Cerebral LLC Basketball organization, coaches and staff from all liability that may occur while participating in our basketball program. I/We give my/our consent and approval to the participation of our child in the Mindful Hoops Basketball Training programs. I/We hereby discharge, waive, and release Beyond Basketball Training, its coaches, staff, and sponsors, from all liabilities. I/We carry personal medical insurance for my/our child in case of accident, injury or illness.

PARENT/GUARDIAN SIGNATURE: ____________________________

DATE: ________________