St. Thomas High School after school Basketball Program

Athlete Information

Athlete's Name *

First Name Last Name

Birth Date *

Month Day Year

Grade *

Gender *

Male Female

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent/Guardian Information

Name *

First Name Last Name

Home Number

Cell Number *

E-mail *

example@example.com

Emergency Information

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number *

Alt. Phone Number

Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe. *

Is the athlete prescribed an inhaler? If yes, please explain any instructions. *

Is your son/daughter permitted to leave Uphill Training Facility located at 3280 Jean-Yves, Kirkland upon finishing? *

Yes No

If NO, who are the individuals permitted to pick up the athlete in question?

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Uphill Athletic Resources during the selected program. In exchange for the acceptance of said child’s candidacy by Uphill athletic Resources ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Uphill Athletic Resources and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected sessions. In case of injury to said child, I hereby waive all claims against Uphill Athletic Resources including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the {Organization} . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature *

Clear