Save the Date

Roselle Park High School PTSA

presents

The Harlem Wizards

vs.
The Roselle Park All-Stars
(Featuring RP staff, Administrators, Coaches, Council Members, and more)

Tuesday April 26, 2011

In the RPHS gym
7pm – 10 pm
Tickets

$10.00 in advance
$15.00 at the door
(if available)

Tickets will go on sale beginning March 21

Proceeds will go toward the Scholarship Fund for the RPHS Class of 2011
 Medical Information & Release Form
Participant’s Name:
_____________________________________________________________

Age: _________ Date of Birth: ___________________ Gender:  Male 

Female

Parent/Guardian Name (if minor):

_________________________________________________

Parent/Guardian Cell: ______________________ Home:

________________________

Emergency Contact: ________________________________ Relation:

___________________

Emergency Contact Number: ______________________________

Primary Doctor: _______________________________ Phone:

_________________________

Health Insurance Provider: _________________________ ID Number:

___________________

Please list any medical conditions, medical history or drug allergies that we should be aware of
(i.e. recent illness, asthma, allergies, etc). Also, please list any restricted activities. If none, please
write NONE.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Is the participant currently taking any medications? Please include prescription medications and
any over the counter drugs. If none, please write NONE.
______________________________________________________________________________
______________________________________________________________________________

Parent/Guardian Authorization
I hereby certify that the information listed above is true and correct. I submit that the participant
is physically fit to participate in strenuous activity and waive the Harlem Wizards of any
responsibility for injury or illness. In the event that I can not be reached in an emergency, I
hereby give permission for (Sponsoring Organization) to hospitalize and secure proper treatment
for the participant as named above.

Parent/Guardian Signature: ________________________________ Date:

________________

Printed Name: ______________________________________________________

Please note that this information will be kept confidential and in a safe place on-site at the event.

Release, Waiver, Discharge, and Covenant Not To Sue

In consideration of the permission granted by ________________, a non-profit corporation operating
under the laws of the State of ________________, hereinafter referred to as SPONSOR for me to
participate in the basketball game and related activities on __________ at___________________. I the
undersigned, hereby RELEASE, WAIVE, DISCHARGE, and COVENANT NOT TO SUE
_________________ or the Harlem Wizards, hereinafter referred to as HARLEM WIZARDS, including
its respective Board members, officers, employees, agents, and affiliates (such affiliates including herein),
from any and all liability, as defined herein, arising out of, or in connection with my participation in the
above described game, including any travel relating thereto. For the purposes of this agreement, liability
means all claims, demands, losses, causes of action, suits or judgments of any and every kind that I, my
heirs, executors, administrators or assignees may have against SPONSOR or HARLEM WIZARDS, or that
any other person or entity may have against them, because of any death, personal injury or illness, or
because of any loss or damage to property belonging to me that occurs during the above described game
and activities, whether caused by the negligence of SPONSOR or HARLEM WIZARDS.

I am fully aware of the risks and hazards connected with participating in the above-described game and
activities, including the risk of injuries and death, and I hereby elect to voluntarily participate therein. I
VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR THE RISKS OF LOSS, PROPERTY DAMAGE
OR PERSONAL INJURY, INCLUDING DEATH, that may be incurred as a result of participating in the
therein.

INDEMNIFICATION AND HOLD HARMLESS I further agree to INDEMNIFY AND HOLD

HARMLESS SPONSOR and HARLEM WIZARDS, from any and all loss, liability, damages, court costs,
and attorney's fees, that I may incur while I am participating in the above described game and activities
WHETHER CAUSED BY ANY NEGLIGENCE ON MY PART, ON THE PART OF SPONSOR OR
HARLEM WIZARDS or otherwise, and whether foreseen or unforeseen.

RULES AND REQUIREMENTS I further agree to accept all rules and requirements of the above
described game and related activities and to follow the instructions given by the supervisory personnel and
grant the right to terminate my participation in the above described game and related activities if it is
determined that my conduct is detrimental to the best interests of SPONSOR and HARLEM WIZARDS

MEDICAL CONSENT In the event of medical emergency, I hereby give permission to supervisory
personnel at the game to authorize any medical, dental, or surgical diagnosis or treatment, x-ray
examination, anesthetic, and hospital care that may be necessary for my safety and protection.

Initial the following statement(s) if applicable:

2
_______I am 18 years of age or older and I will be a participant in the above described game and
related activities. I have read, understand, and agree with the terms on this form.

_______I am the parent or legal guardian of the participant who is under 18 years of age to whom the
above statements apply and for whose benefit I am executing the agreement. I have read the contents of
this Release, Waiver, Discharge, and Covenant Not to Sue, Indemnification and Hold Harmless agreement;
Rules and Requirements; and Medical Consent and I (we) understand its terms. I (we) execute it
voluntarily and with full knowledge of its significance.

_________________________________ _______________________________________
Signature of Participant or Parent/Guardian Printed Name