Moses E. Cheeks Slam Dunk Basketball Camp For Diabetes Application Form
 
!!!!!!!!! Please print out form, complete and SNAIL MAIL to address below.
Snail mail form to:  Monica Joyce - 9812 S. Damen - Chicago, IL  60643
Camp Dates:  Closed until 2009
To be held at:  DeLaSalle Institute - 3434 S. Michigan - Chicago, IL
Morning session are for ages:  5-10   -  Afternoon sessions are for ages 11-18
Camp is open to boys and girls with diabetes.  Space is limited to 30 participants per session.*
Please print clearly
Mr.   Mrs.   Ms.   (circle one) Camper's Name:
(Parent/Guardian Name)*                         
  Camper's Date of Birth:         /          /             Sex:   M   F                            
Home Phone Number:  (           )  
                 Date of Camper's Diagnosis:              /        /          
Camper's Age:   _____yrs.  
  Email Address:
Address:  
  Emergency Contact (Name & Phone Number):           
City, State and Zip Code:  
   
Camper's T-Shirt Size (circle one)            S     M    L    XL    XXL   


Waiver, General Release and Covenant Not to Sue:
As parent/legal guardian of____________________________________________________(participant), I hereby give my consent to Participant's participation in the program to be held at De LaSalle Institute.  I acknowledge that participation in the program involves the risk of personal injury to Participant or others.  Understanding that risk and in consideration of Participant being allowed to participate in the program, I, on my own behalf, and the behalf of Participant, Participant's heirs, administrators, executors and assigns, hereby (i) fully release and discharge the Chicago Professional Sports Limited Partnership, Chicago Bulls Limited Partnership and CBLS Corporation, The National Basketball Association and its team members,  NBA Properties, Hocleb Athletic Instruction, LLC, Chicago White Sox, Ltd, Chisox Corporation, and all of its affiliates (the Releasees), from any and all claims, demands, liabilities or causes of action of whatsoever kind or natures, in longevity or otherwise which hereinafter may accrue against them and which in anyway arise as a result of Participant's participation in the Program, regardless of whether based on fault or negligence of the Releasees, (ii) covenant not to sue any of the Releasees for any and all losses, damages, costs or expenses (including attorney's fees and other costs of defense) which any of them may sustain as a result of, or in connection with, Participant's participation in the Program.  I have read this Waiver and General Release and Covenant Not To Sue and Refund/Cancellation Policy carefully and fully understand the contents.  I am aware that this is an agreement not to sue the Releasees and constitutes a complete release of liability by me and by Participant in favor of the Releasees.  I acknowledge that I am signing this document of my own free will, with full knowledge of the risks being assumed which include, without imitation, the risk of injury or death to Participant regardless of how it arises and even if it results from the negligence or fault of the Releasee.


Signature:___________________________________________________________________Date:__________________________________

*Parent/Guardian must attend check-in to meet with the medical staff.