BENNETT BLAZERS

WEEKEND OF GAMES

DECEMBER2&3, 2017

Bennett Institute

3835 Greenspring Avenue

Baltimore, MD 21211-1398

443-923-7844

(CELL) 410-322-6275

Dear Team Representative,

The Bennett Blazers are pleased to announce our weekend of games for 10 Foot & Prep Junior Eastern Conference Teams. We will start AT 9:00 AM on Saturday. All Varsity teams will play at least 3 games in a round robin format. Prep will play at least three games, with an option for a third game in a one day format

All games will be played at the Bennett Institute Gym located at the address above.

NOTE

All Rosters forms and checks

Must be received by Gerry Herman by 11/17/17 or your team will be eliminated from the event

Registration Fee:

$200 Per Team

Make Checks Payable to:

Kennedy Krieger

And send to:

Gerry Herman

Bennett/KKI

3835 Greenspring Avenue

Baltimore, MD 21211-1398

BENNETT BLAZERS

WEEKEND OF GAMES

TEAM REGISTRATION FORM

DECEMBER 2&3, 2017

BENNETT INSTITUTE

CIRCLE YOUR TEAMS DIVISION

10 foot_____PREP

Team Name_____________________________________________________________

Coach/Team Rep name____________________________________________________

Phone Numbers (w) ___________________________(h)_________________________

Cell Phone______________________________________________________________

TOTAL NUMBER ATTENDING PLAYERS/COACHES______________________

JERSEY # PLAYER NAME AGE

1.______________________________________________________________________

2.______________________________________________________________________

3.______________________________________________________________________

4.______________________________________________________________________

5.______________________________________________________________________

6.______________________________________________________________________

7.______________________________________________________________________

8.______________________________________________________________________

9.______________________________________________________________________

10._____________________________________________________________________

11._____________________________________________________________________

12._____________________________________________________________________

BENNETT INSTITUTE

PHYSICALLY CHALLENGED SPORTS

Name___________________________________________________________________

Player/Coach First Name______________________Last Name__________________

Date of Birth (m/d/y)_____/____/____age_______________Male_____Female______

Street address___________________________________________________________

City_______________________________State_____________Zip_________________

Emergency Contact Name____________________________Relation______________

Phone Number(s)________________________________________________________

Audio Visual Consent: I hereby authorize the taking of photographs, films, videotapes or reproductions while attending the Bennett Institute Programs and consent to it’s use for promotional, or publicity purposes on the part of the Bennett Institute Physically Challenged Sports Program of Kennedy Krieger. I hereby grant Bennett Institute/KKI the right and irrevocable authority to such reproductions. I waive any and all claims for compensation and all claims related to or arising out of the publication and dissemination of the same of any lawful purposes. I further authorize the communication of information in connection with the utilization of such reproductions by Bennett Institute/KKI and it’s affiliated organizations without the claim for compensation and waive all claims arising out of the publication and dissemination of the same______________(initial)

Consent for Emergency Treatment: I hereby give permission for the child named above to participate in the Bennett Institute Physically Challenged Sports Program . In the event that the participant should sustain any injuries while participating, I understand that he/she may be examined and treated for emergency injuries by healthcare personnel, including examinations at health care facilities._____________(initial)

Release and Indemnification: I hereby release the Bennett Institute Physically Challenged Sports Program of Kennedy Krieger and all affiliated and associated organizations, together with their respective trustees, directors, officers, employees and agents of any and all claims, causes of action, suits, damages, judgments, or liabilities of any kind or nature arising out of or in any way related to the participation in Bennett Institute Programs, including any personal injury or death, which he/she may incur as a result of participation, whether or not caused by the negligence or wrongful acts. This release shall be binding upon the heirs, next of kin, guardians, executors and administrators of the participant. I also agree to indemnify and hold harmless all claims, or actions of any kind or nature arising from any injury incurred. I acknowledge that I am over 19 years of age, am of sound mind, have signed this form voluntarily, and that this release contains the entire agreement between me, Bennett Institute Physically Challenged Sports and Kennedy Krieger Institute._______________(initial)

I have read, understood and completed this questionnaire. Any questions that I had were answered to my full satisfaction.

Parent/ Guardian Signature______________________________________________________________