Basketball League Registration Form

XCELLING YOUTH ZONE 2022

Registration Form

goldeneaglesxyz@gmail.com

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Athlete Information
Player Name

First NameLast Name
Player Age
Player Grade
Player D.O.B

MonthDayYear
Date
Guardian / Parent's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
E-mail

Basketball skill level

	1	2	3	4	5

1 is Beginner, 5 is Advanced

Interested in Volunteering while your team is not playing?

Other
Emergency Contact & Health Insurance Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Parental Permission For Emergency Treatment: In the event of illness or accident: I give my permission for emergency treatment by qualified medical personnel for my child. I give consent for the Golden Eagles Youth Basketball Organization to secure any and all necessary emergency medical care for my child.
I have read and agree to the above conditions
Do you have health insurance ?
Insurance Carrier
Name of Policy Holder
Subscriver ID/Group Number
Card Number / Card Date
Does your athlete have any allergies, chronic illness, or medical conditions that would limit high level activtiy?
Please describe
Name of Physician / Emergency Medical Care Facility
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Release of Liability Although the safety of all sport activities is the primary concern, indoor sport activities may cause injuries and/or death. I expressly assume the risk of injury, death, and/or illness arising from any cause, and agree to waive the right to pursue any claim against the Golden Eagles Youth Basketball Organization and the persons in charge.
I have read and agree to the above conditions
Confirmation E-mail
Signature
After completing this form, please click Submit Form. You will receive a confirmation email. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at goldeneaglesxyz@gmail.com .
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XCELLING YOUTH ZONE 2022

Registration Form