Basketball League Registration Form

Fusion Basketball Academy - Registration Form (9th-11th grade ) Spring / Summer Season

Athlete Information

Player Name

First NameLast Name

Are you over 18 ?

Guardian / Parents Names

First NameLast Name

Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Home Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

E-mail

Grade Level

	9	10	11

9 is 9th, 11 is 11th

I would like to play on the same team with following players. League organizers will form teams base on this your skill level.

Important Notes · Dress appropriately. · Keep the gym clean. · Fee: $10 (cash) per participant.

Emergency Contact & Health Insurance Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Does you have any allergies, chronic illness, or medical conditions that would limit high level activtiy?

Please describe

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, and I authorize the person in charge to take my child to: I give consent for the facility to secure any and all necessary emergency medical care for my child.

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 at Youth Sport Center's facilities 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 Youth Sport Center 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 Ilfusionacademy@gmail.com