Illini Elite VBC

Player Information

Player First Name *

Player Last Name *

Date of Birth *

School *

Grade *

--- Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade

Player Cell Phone

Please provide in the following format; XXX-XXX-XXXX

Home Address *

City *

State/Province *

Zip *

Country *

Medical Conditions *

Parent Contact Information

Parent Email Address *

Parent Phone *

Cancellation Policy

Cancellation Policy: If you need to cancel your registration, you can receive a refund minus a $50 administrative fee if the cancellation occurs two weeks prior to the start of the activity. No refunds can be given if the cancellation occurs less than two weeks prior to the start of the activity. Please contact Andy or Joe at (309) 829-3671 if you need to cancel a registration.

Payment Policy

You must pay the activity fee to finish registration. If you have not paid the activity fee, you will not be considered registered.

Waiver Release and Insurance Information

AS CUSTODIAL PARENT OR COURT-APPOINTED GUARDIAN OF THE CHILD ABOVE, I DO FOR BOTH OF CHILD’S PARENTS, FOR CHILD AND CHILD’S HEIRS AND SUCCESSORS, RELEASE ILLINI ELITE VOLLEYBALL, INC. AND ANY OF ITS AGENTS, EMPLOYEES OR REPRESENTATIVES (ALL OF THE FOREGOING COLLECTIVELY "ILLINI ELITE VBC") FROM ALL CLAIMS ARISING OUT OF OR CONNECTED WITH CHILD’S PARTICIPATION IN ANY ILLINI ELITE VBC PROGRAM. I PROVIDE THIS RELEASE BECAUSE I AM MINDFUL THAT ATHLETICS, PHYSICAL TRAINING AND COMPETITION CAN BE A DANGEROUS UNDERTAKING REGARDLESS OF HOW CAREFUL OR PRUDENT ANY PERSON, FIRM OR FACILITY MIGHT BE. FURTHER, I GIVE PERMISSION TO ILLINI ELITE VBC TO TREAT CHILD OR ARRANGE FOR MEDICAL CARE OR TREATMENT FOR CHILD IN ANY SITUATION DEEMED REASONABLY NECESSARY BY ILLINI ELITE VBC IF CIRCUMSTANCES PERMIT, ILLINI ELITE VBC SHALL ATTEMPT TO COMMUNICATE FIRST VIA TELEPHONE WITH THE EMERGENCY CONTACT.

In the event neither emergency contact can be reached or if the urgency of the situation requires immediate attention without prior telephone contact, ILLINI ELITE VBC may arrange for medical treatment for the Child at the expense of the parent or guardian signing this form. Health Insurance, PPO information for Child is as follows:

Insurance Information

In the event neither emergency contact can be reached or if the urgency of the situation requires immediate attention without prior telephone contact, Illini Elite VBC may arrange for medical treatment for the Participant at the expense of the parent or guardian signing this form. Health Insurance, PPO information for Participant is as follows: 

Insurance Company *

Policy Number

Parent/Guardian Type Full Name *

By typing your name in the signature box and clicking submit, you agree that you are electronically signing this agreement in accordance with the Electronic Signatures Act (Public Law No: 106-229), and agree to be bound by all terms and conditions.