IMAGO DEI MINISTRIES

"One Family, One Vision, One Accord"

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Team Major

Home
IDM Family
Mentoring Programs
Panthers Basketball
Annual Benefit
Online Store
Contact Us
Team Major

Team Registration Packet

Player's Full Name*

Date of Birth *

Age*

Height*

Player's Phone *

Player's Email Address

Name of School*

Grade In School *

Do you currently play basketball for your school's team?*

YesNo

Have you played for the Panthers before?*

YesNo

Position(s) You Play *

Point GuardShooting GuardSmall ForwardPower ForwardCenter

Parent/Guardian's Name*

Parent/Guardian's Phone*

Parent/Guardian's Email Address

Address*

City, State, Zip*

I hereby give permission for my child to participate in the Imago Dei Ministries, Inc., Panthers Basketball Program, in Chicago and any other place where training is held in which they are a participant, while participating with the Panthers Basketball I understand that this program includes running, jumping, throwing and other skills. There is an inherent risk in basketball. Injuries include but are not limited to sprained ankles, muscle pulls, and injury to joints, bones, ligaments& tendons, neck & back injuries, and even death. In an effort to make the program run more safely, it is vital that all athletes follow instructions given. *

______________________________________________________________________ Parental Consent

AgreeDisagree

I grant permission for the administration to render first aid to my child by the people in charge of the Imago Dei Ministries, Inc. Panthers Basketball Program and those transporting my child to and from the program as their judgment deems advisable and to make the necessary referrals to qualified physicians for treatment of illnesses or accidents of a more serious nature. I understand that I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when delay in such communication would endanger life. In case of medical emergency, I understand that every effort will be made to contact the parent/guardian of the participant in the event I cannot be reached, I hereby give permission to the physician selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery, if deemed necessary for my child. *

_________________________________________________________________________ Parental Consent

AgreeDisagree

I consent to the use of my name, voice, likeness, picture, quotation, comment, testimonial, and/or tips (individually or collectively, the “Submissions”) by IDM Panthers Basketball, its parent company, and their subsidiaries, related or affiliated companies (“collectively, “Company”), for advertising, trade, and any other lawful purpose, together with the right to copyright and publish the same and/or permit registration as a trademark or service mark with respect to any materials incorporating the Submissions.*

_________________________________________________________________________ Parental Consent

AgreeDisagree

I also grant Company a non-exclusive, irrevocable, worldwide, royalty-free license to reproduce, distribute, and publicly display the Submissions (including, but not limited to, my photograph, as well as my first name, last initial, home state), in promotions and other publications in any and all media, in any locale, in perpetuity, for any purpose whatsoever, without any compensation, provided it is understood that Company shall not utilize my submission in any way to intentionally and maliciously subject me to conspicuous ridicule or indignity. I grant Company the right to edit my Submissions.*

_________________________________________________________________________ Parental Consent

AgreeDisagree

I hereby release and indemnify Imago Dei Ministries, Inc., its staff, its volunteers, and the gym location that is used as the host site, from any and all liability arising from claims of any kind or nature whatsoever from my child's participation in this program.*

_________________________________________________________________________ Parental Consent

AgreeDisagree

Participating Players/Families understands that there is an inherent danger and risk of exposure to novel coronavirus (SARS-CoV-2) in public places where people are present. This includes any mutations, adaptations or variations of COVID-19. Participating Players/Families understands that COVID-19 is a very dangerous and highly contagious disease that has been shown to cause severe illness and death. Participating Players/Families understands that no precautions can eliminate the risk of exposure to COVID-19, and that the risk of exposure to this disease applies to everyone. The Centers for Disease Control (CDC) has reported that senior citizens (people over 65 years of age) and people with underlying medical conditions are especially vulnerable. Participating Players/Families also understands that contracting COVID-19 can result in transmission to family members and friends. By participating in our program, including but not limited to our practice facilities and tournament venues, Participating Players/Families knowingly and voluntarily agrees that they are assuming all risks in any way related to exposure to COVID-19, including any illnesses, injuries, or even death. Participating Players/Families, along with their heirs, family, next of kin, or executors, hereby agrees to release, covenant not to sue, and forever discharge Imago Dei Ministries, Inc., and all of its practice sites from any and all liabilities, claims, causes of action, damages, costs or expenses of any kind related to exposure to COVID-19 while present or participating in any activity sponsored by Imago Dei Ministries. This includes any claims related in part or in whole to both passive and active negligence of Imago Dei Ministries, Inc. Participating Players/Families further agrees to indemnify and hold harmless Imago Dei Ministries, Inc. and all of its practice sites from any and all such claims, damages, injuries brought against the Imago Dei Ministries, Inc. related to COVID-19. Participating Players/Families expressly agrees that this release, indemnification and hold harmless provision shall apply to all physical and emotional injuries including death that may occur during my presence or involvement with sponsored activities of Imago Dei Ministries, Inc.*

______________________________________________________________________ Parental Consent

AgreeDisagree

Participating Players/Families understands and agrees that they will abide by any and all CDC, IDPH, Cook County Health Department or Imago Dei Ministries, Inc. Health Guidelines that are in effect at the time of programming. Participating Players/Families also understands and agrees that failing to follow any CDC, IDPH, Cook County or Imago Dei Ministries, Inc. Guidelines at the time of programming will result in immediate ejection of the participating player.*

______________________________________________________________________ Parental Consent

AgreeDisagree

Please list all known medical conditions that could be impacted while playing basketball*

Authorized Physician's Name

Physician's Phone

Insurance Company

Policy Number

In the case of an emergency the staff of Imago Dei Ministries, Inc. should contact:

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Panther Program Information

Team Name: IDM Panthers Established: 2009 Colors: Black & Gold

Age Groups: 10U, 16U, 17U

Staff: Mario Jackson* - Program Director & 17U Coach

Burton Anderson - 16U Coach

Victor Junious* - Program Assistant Coach

Charles Shipp* - Program Assistant Coach

Javaree Junious* - Program Assistant Coach

Shannon Carroll* - Manager

* = (Certified USA Basketball Coach)

Season: March - July (There will be no practices in June to allow players to play summer league for their high school)

Team Roster: 8 - 10 players per roster

Eligibility: Players cannot be committed to any other AAU, Travel, or Club team

Practice Facilities:

Blue Island Rec, 2805 141st St, Blue Island, IL 60406

Calumet Park Rec, 12426 S Loomis St, Calumet Park, IL 60827

Robbins Community Center, 13800 S Trumbull Ave, Robbins, IL 60472

Eisenhower High School, 12700 Sacramento, Blue Island, IL 60406

Palmer Park, 201 E. 111th Street, Chicago, IL 60628

Program Fees: $450 (Fees will cover tournament costs, insurance, equipment, uniform maintenance, travel expenses, etc.)

Deadline: All fees should be paid in FULL by Friday, April 8, 2022.

Fundraising: All families are required to participate in program fundraising. Details will be provided during orientation.

Orientation: There will be a mandatory parent and player orientation after tryouts have been concluded and the program rosters have been posted. The orientation is scheduled for Tuesday, March 8, 2022.

Communication: Our website is the BEST way to stay connected and informed. You are encouraged to check it weekly. The schedule for the season including practices and games will be posted on the site and will be updated weekly as things change. Each coach’s phone number will be listed on the bottom of the schedules. If you have concerns that are not answered on the site please contact your Head Coach. If your Head Coach is unavailable or if more assistance is required then contact the Program Director, Mario Jackson.

Forms of Payment:

Cash

Money Order Payable: Imago Dei Ministries

Zelle: [email protected]

PayPal

Use the dropdown arrow to make the appropriate payment selection

Program Fees

Player's Name

Phone: 800-362-7925

Fax: 877-459-7066

Email: [email protected]

Mailing: P.O. Box 439328 - Chicago, IL 60643