2022 SUMMER BASKETBALL LEAGUE

2022 SUMMER BASKETBALL LEAGUE
Participant Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Age blanks* Date of Birthblank* Grade blank*
Parent/Guardian Name

First NameLast Name
Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please list medical conditions and Allergies
Insurance

Name of CarrierPolicy Number
Email
example@example.com
Liability Waiver S.M.A.A Basketball Summer League participant and /or their guardian, in consideration for the township and Individuals assisting to provide faculi9ties, instru8ctions, transportation and supervision the activity for which the participant has registered does hereby.

1. Request participate in said activity with the full knowledge that said activity could result in personal injury or damage to my personal property.

2. Assume all risks and possible damage or injury involved through participation in said., I understand I am to furnish my own insurance in case of injury.

3.Agree to indemnify and hold harmless the Township and its agents for personal injury or property damage to other parties resulting from my participation or the anticipation of minors in my custody while engaged in the said activity

4. I agree that Township shall have the right to enforce activity rules and terminate participation by anyone failing to comply with said rules.

5. I will furnish a certified certificate of birth or proof of birth of the above names upon request program directors.

6.Waive the right dispute all proper charges received.

7. I agree to reimburse township for any and all fees incurred for wrongfully disputing a credit charge
Signature
Date

MonthDayYear
Date
Photo /Video release I hereby give my permission for images of my child captured during basketball camp or programs to be used solely for the purpose of S.M.A.A basketball promotional materials, publications and team photo galleries and waive any rights of compensation
Signature
Date

MonthDayYear
Date
PLEASE MAKE CHECKS PAYABLE TO: SMAA

CASHAPP PAYMENTS: $SMAAYOUTHSPORTS
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