Do you currently play basketball for your school's team?*
Have you played for Team Major Eagles before?*
Parent/Guardian's Email Address
I hereby give permission for my child to participate in the Imago Dei Ministries, Inc., Panthers Basketball Program, in Chicago and any other place where training is held in which they are a participant, while participating with the Panthers Basketball I understand that this program includes running, jumping, throwing and other skills. There is an inherent risk in basketball. Injuries include but are not limited to sprained ankles, muscle pulls, and injury to joints, bones, ligaments& tendons, neck & back injuries, and even death. In an effort to make the program run more safely, it is vital that all athletes follow instructions given. *
I grant permission for the administration to render first aid to my child by the people in charge of the Imago Dei Ministries, Inc. Panthers Basketball Program and those transporting my child to and from the program as their judgment deems advisable and to make the necessary referrals to qualified physicians for treatment of illnesses or accidents of a more serious nature. I understand that I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In case of medical emergency, I understand that every effort will be made to contact the parent/guardian of the participant in the event I cannot be reached, I hereby give permission to the physician selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery, if deemed necessary for my child. *
I consent to the use of my name, voice, likeness, picture, quotation, comment, testimonial, and/or tips (individually or collectively, the “Submissions”) by IDM Panthers Basketball, its parent company, and their subsidiaries, related or affiliated companies (“collectively, “Company”), for advertising, trade, and any other lawful purpose, together with the right to copyright and publish the same and/or permit registration as a trademark or service mark with respect to any materials incorporating the Submissions.*
I also grant Company a non-exclusive, irrevocable, worldwide, royalty-free license to reproduce, distribute, and publicly display the Submissions (including, but not limited to, my photograph, as well as my first name, last initial, home state), in promotions and other publications in any and all media, in any locale, in perpetuity, for any purpose whatsoever, without any compensation, provided it is understood that Company shall not utilize my submission in any way to intentionally and maliciously subject me to conspicuous ridicule or indignity. I grant Company the right to edit my Submissions.*
I hereby release and indemnify Imago Dei Ministries, Inc., its staff, its volunteers, and the gym location that is used as the host site, from any and all liability arising from claims of any kind or nature whatsoever from my child's participation in this program.*
Participating Players/Families understands that there is an inherent danger and risk of exposure to novel coronavirus (SARS-CoV-2) in public places where people are present. This includes any mutations, adaptations or variations of COVID-19. Participating Players/Families understands that COVID-19 is a very dangerous and highly contagious disease that has been shown to cause severe illness and death. Participating Players/Families understands that no precautions can eliminate the risk of exposure to COVID-19, and that the risk of exposure to this disease applies to everyone. The Centers for Disease Control (CDC) has reported that senior citizens (people over 65 years of age) and people with underlying medical conditions are especially vulnerable. Participating Players/Families also understands that contracting COVID-19 can result in transmission to family members and friends. By participating in our program, including but not limited to our practice facilities and tournament venues, Participating Players/Families knowingly and voluntarily agrees that they are assuming all risks in any way related to exposure to COVID-19, including any illnesses, injuries, or even death. Participating Players/Families, along with their heirs, family, next of kin, or executors, hereby agrees to release, covenant not to sue, and forever discharge Imago Dei Ministries, Inc., and all of its practice sites from any and all liabilities, claims, causes of action, damages, costs or expenses of any kind related to exposure to COVID-19 while present or participating in any activity sponsored by Imago Dei Ministries. This includes any claims related in part or in whole to both passive and active negligence of Imago Dei Ministries, Inc. Participating Players/Families further agrees to indemnify and hold harmless Imago Dei Ministries, Inc. and all of its practice sites from any and all such claims, damages, injuries brought against the Imago Dei Ministries, Inc. related to COVID-19. Participating Players/Families expressly agrees that this release, indemnification and hold harmless provision shall apply to all physical and emotional injuries including death that may occur during my presence or involvement with sponsored activities of Imago Dei Ministries, Inc.*
Participating Players/Families understands and agrees that they will abide by any and all CDC, IDPH, Cook County Health Department or Imago Dei Ministries, Inc. Health Guidelines that are in effect at the time of programming. Participating Players/Families also understands and agrees that failing to follow any CDC, IDPH, Cook County or Imago Dei Ministries, Inc. Guidelines at the time of programming will result in immediate ejection of the participating player.*
Please list all known medical conditions that could be impacted while playing basketball*
Authorized Physician's Name
In the case of an emergency the staff of Imago Dei Ministries, Inc. should contact:
