Open Gym | Adult Basketball

General Information

First Name

Nombre

Last Name

Apellido

Phone number

Numero de telefono

Date of Birth

Fecha de nacimiento

Numero de telefono

Disclaimer

EMERGENCY MEDICAL AUTHORIZATION, HOLD HARMLESS AGREEMENT & CONSENTS:

In the event a participant is injured or becomes ill while participating in a program offered through the Nantucket Boys & Girls Club, it is the judgment of the staff on the severity of the illness or injury and if it requires immediate attention, the Nantucket Boys & Girls Club is authorized to obtain such medical assistance as deemed necessary or proper, including, but not limited to; appropriate medical treatment at Nantucket Cottage Hospital. In order to provide this authorization, this Hold Harmless Agreement and Consent form must be signed below and left with the Nantucket Boys & Girls Club. Participant understands and agree to save and hold the Nantucket Boys & Girls Club, Inc. its agents, servants and employees, harmless from any and all liability in any way for any occurrence in my voluntary enrollment in this activity which may result in bodily injury, property loss or damage, death or other damages to me or my family, heirs or assigns. In consideration of voluntarily participating and being allowed to enroll in this activity, I hereby personally assume all risks for injury in connection with this course/program/activity. I understand I will be financially responsible for any damage I inflict in 2021/2022 on any property of the Nantucket Boys & Girls Club and may also lose the privilege of participating in any/all Programs. I further state that I am of lawful age and legally competent to sign this affirmation and release; that I understand the terms herein are contractual and not a mere recital; and that I have signed this document as my own free act. Furthermore, if registering for an activity that involves physical exertion, I state that I am physically fit, have consulted with a physician and assume my own risk of injury. I have fully informed myself of the contents of this affirmation and release by reading it before I signed it.

Data Collection

I give my permission to the Nantucket Boys & Girls Club to collect information via online or written surveys, questionnaires, interviews and focus groups from the person listed on the registration. Any and all information received will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all reference to any individual responses. The results of these analyses may be shared with Club staff, Boys & Girls Clubs of America, funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members.

Miscellaneous

I understand the Nantucket Boys & Girls Club is not responsible for lost or stolen items.

Nantucket Boys & Girls Club complies with regulations of the Massachusetts Department of Public Health and is licensed by Nantucket Health Department. Parents may request copies of background checks, health care and discipline policies, by contacting the Executive Director.

COVID Assumption of Risk & Waiver Letter

Dear NBGC Participant,

As you are certainly aware, COVID-19 is an extremely contagious communicable illness that is spread through person-to-person interactions. Not all individuals infected with COVID-19 display any symptoms, but such individuals may nonetheless be contagious and spread the infection. State and local authorities are closely monitoring the spread of COVID-19 in the Commonwealth of Massachusetts and on Nantucket, and have introduced mandatory quarantines, social distancing and other safety measures to prevent the spread of the disease. Please also note that the Club’s plans will also be subject to change based on evolving guidance and changes in federal, state and/or local mandates or guidance.

Although NBGC will comply with all applicable safety requirements, so long as COVID-19 continues to spread by community transmission and until there is an effective vaccine, there will be a risk that members could become infected with COVID-19 despite those efforts.

That risk extends to the families of members as well.
By electing to enter the Nantucket Boys & Girls Club this school year, you acknowledge and agree that the safety policies and procedures outlined above are reasonable under the circumstances, and that there is nonetheless a risk that your child could contract COVID-19 and/or become a symptomatic and/or asymptomatic carrier of COVID-19 despite the above safety policies and procedures.
By signing below, you knowingly and voluntarily assume that risk, as well as the risk that such infection could spread to other members of your child’s household or family.
By signing below, you hereby agree, on your own behalf and on that of your child, and of your heirs, executors, administrators, personal representatives, and/or assigns (“Releasors”), to forever release, acquit, discharge, and covenant to hold harmless Nantucket Boys & Girls Club, its trustees, employees, volunteers, representatives, and agents (“Releasees”) from any and all claims, suits, liabilities, and actions, including, but not limited to, any negligence of Releasees, which Releasors may have, now or in the future, which relate in any way to your child contracting COVID-19, or any symptoms or complications arising from COVID-19, as a result of attending any NBGC programs.

Further, by signing below, you agree that you or anyone in your immediate household will abide by applicable terms of the Club’s plans, including without limitation, a 14-day self-quarantine if you travel out of state, and/or if anyone newly arrives to reside in your household from out of state. Questions about travel out of the country or out of the state will be addressed to you throughout the school year, as part of the Club’s plans.

Finally, in these uncertain times, you understand and agree that the duties and obligations of the Club may be modified or suspended immediately and without notice because of causes beyond the Club’s control, such as threats to the health and safety of members and staff, including the Covid-19 pandemic or actions by Government officials or health officials regarding the pandemic. If such an event occurs, you acknowledge and agree that the Club is not obligated to provide any refunds of payments made to the Club.

Sincerely,

Jamie Foster

Executive Director

Acknowledgement
Entering my name below indicates that I have read and understand the policies and expectations detailed on this form. I understand that my failure to comply with the stated expectations may jeopardize my enrollment for Nantucket Boys & Girls Club Adult activities.

Pricing

$10 Drop in fee per session.