2007-2008 AGREEMENT TO PARTICIPATE
READ CAREFULLY – THIS FORM MUST BE RETAINED BY THE HEAD COACH
I understand there are several inherent risks involved in athletic participation in the sport of basketball and
I voluntarily assume all such risks. I, intending to be legally bound, do hereby, for myself, the athlete,
heirs, executors, and administrators, waive, release, and forever discharge any and all rights and claims for
damages which may have or which may hereafter accrue to the athlete against FAUQUIER KNIGHTS
BASKETBALL, the Virginia District of the Amateur Athletic Union, the Amateur Athletic Union of the
US, the National AAU Committee, the sponsors and officials of any basketball event in which the
FAUQUIER KNIGHTS club participates in, the owners of facilities in which events, scrimmages, or
practice sessions are held, or any other support group of organizations, and their respective directors,
officers, agents, members, coaches, sponsors, parents, volunteers, representatives, successors, and assigns
for any and all damages which may be sustained and suffered by the athlete in connection with his or her
entry or participation in any basketball event, scrimmage, or practice session involving
FAUQUIER KNIGHTS club whether or not sanctioned by the AAU or any governing body or which may
arise out of traveling to and from said events including lodging.
I, or we, grant to the coaches, trainers, adult volunteers, tournament directors, or other assigned chaperones
to act as guardian/spokesman in granting permission for emergency treatment/hospitalization (including
anesthesia) if necessary for my child while en route to or from or at the site of any basketball event,
scrimmage, or practice session. Should a health emergency arise such medical treatment as deemed
necessary by competent medical personnel is authorized.
I hereby authorize FAUQUIER KNIGHTS BASKETBALL and the AAU to allow the reproduction,
dissemination, and/or publication of my name and likeness for media coverage, public relations, or any
other purpose, which may involve the use of photographs, films, or video tape recording without
remuneration.
I agree to pay for any damage or theft caused by the athlete to property including but not limited to locker
rooms, vehicles, or hotel rooms. I agree to pay for any long distance telephone calls, movies, or other extra
costs charged to the athlete’s hotel room. I authorize the assigned chaperones to send my child home early
from events in the event of serious misbehavior including any involvement with illegal drugs or alcohol
and agree to pay for the costs of transportation.
___________________________ _______________ __________________________ _____________
Signature of Athlete                         Date                         Signature  of  Parent/Guardian         Date
MEDICAL AND INSURANCE INFORMATION:
NAME__________________________________________ BIRTH DATE______________________
HOME PHONE__________________________ PARENTS WORK PHONE____________________
EXISTING MEDICAL CONDITIONS, ALLERGIES, AND MEDICATION
_____________________________________________________________________________________
_____________________________________________________________________________________
PHYSICIAN ______________________________________ PHYSICIAN PHONE________________
INSURANCE COMPANY OR PROGRAM
__________________________________________________
POLICY NUMBER
_____________________________________________________________________