Healthy Living EXPO 3-on-3 Tournament to benefit the Cystic Fibrosis Foundation
 WAIVER/RELEASE OF LIABILITY AND OFFICIAL TEAM ROSTER
TEAM NAME:
 DIVISION (CHECK ONE)
 13&Under
 17&Under
 18&Over
If the team consists of minor players (below age 18) this form must be submitted by an adult representative. If no minors are on the
team, one player should represent the team as TEAM CAPTAIN. Only one adult representative (or Coach) is required per team. The
adult listed on this form is responsible for submitting documentation on behalf of the team on the day of the event.
In consideration of being allowed to participate in the Healthy Living EXPO 3-ON-3 BASKETBALL TOURNAMENT, related
events and activities, the undersigned acknowledges, appreciates and agrees that:
1. The risk of injury from the activities involved in the program is significant, including the potential for permanent paralysis and
death, and while particular rules, equipment, and personal discipline may reduce the risk, the risk of serious injury does exist;
and
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE
NEGLIGENCE OF THE RELEASEES or others, and assume all full responsibility for my participation; and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation. If however I observe any
unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the
attention of the nearest official immediately; and
4. I am the parent or legal guardian of the Event participant. I am of legal age and am freely signing this agreement on behalf
of the Event participant. I have read this form and understand that by signing this form, I am giving up legal rights and
remedies on behalf of myself, the Event participant and his/her family, estate, heirs, and/or assigns. I HEREBY RELEASE AND
HOLD HARMLESS "Healthy Living EXPO 3-ON-3 Basketball Tournament", Wiles Chiropractic, their officers, officials,
agents, board members, members and/or employees, other participants, sponsoring agencies, sponsors, advertisers and if
applicable, owners and lessors of premises used to conduct the event (“Releasees”). WITH RESPECT TO ANY AND ALL
INJURY, DISABILTY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF
THE RELEASEES OR OTHERWISE. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK
AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY
SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
5. I grant full permission to the organizers of “Healthy Living EXPO 3-ON-3 Tournament”, with no obligation to compensate me, or
any other participant, to take my picture and use my name, likeness or photographic image (in whole or in part), including but not
limited to the use of my name and likeness in any photographs, videotapes, motion pictures, recordings, internet, or other record of
this event and waive any and all claims against Wiles Chiropractic.
6. I am aware that this is a Release of Liability and Contract between myself and the organizers.
Players Full Name
HEIGHT (Approximate)
 AGE
1.
2.
3.
4.

Adult Teams: Choose one player (TEAM CAPTAIN) to represent the team on this form by completing the information below.
Minor Teams (Any players under 18 years of age): An adult must complete this form and submit it on behalf of all minor players;
that adult (COACH) must represent the minor players on the day of the event. Minors will NOT be allowed to participate in any
game without this adult (COACH) present.
TEAM CAPTAIN / COACH'S NAME:
ADDRESS:
EMAIL
CITY:
 STATE:
 ZIP:
HOME PH:
OTHER PH:
(at least one phone # required)
TEAM CAPTAIN’S / COACH’S VERIFICATION: This is to certify that this roster does not include any assumed names and
that each player conforms to eligibility rule governing The Healthy Living EXPO 3-ON-3 BASKETBALL TOURNAMENT.
SIGNATURE                                                      DATE

Team Captain/Coach check in with all your players at the Registration Table 30 min before your first game.
This ROSTER must match the players submitted on your REGISTRATION FORM.
All players must present a valid photo ID, if applicable. All minor players must present copy of birth certificates.
The following are your payment options:  The registration fee is $30 per team (adult)
and $20 per team (13&Under and 17&Under) - Teams must consist of at least 3 players.

First complete the online registration form above, then:

1. Mail Payments (checks only, payable to Wiles Chiropractic) to:
Wiles Chiropractic
1191 Route 9W
Marlboro, NY 12542
** BE SURE TO INCLUDE TEAM NAMES ON ALL CHECKS **
2.  Bring payment (cash, check or credit card) to the office of Wiles Chiropractic (1191 Route
9W, Marlboro, NY)

Registration form and payment must be received by April 15th, 2010.
There will be NO REGISTRATIONS excepted after April 15th, 2010.
REGISTRATION FORM
REGISTRATION FORM