3v3 Basketball League Registration Form

3x3 youth violence prevention basketball tournament

(ages13-15 and 16-18)

@424 athlete factory - 424 gold way Pittsburgh, Pa 15213

Mondays and Wednesdays 4-6pm

Register by MARCH 5..

STARTS MARCH 13!!

Athlete Information

Team Name*

Player Name*

First NameLast Name

I would like to play on the same team with following 4 players (include yourself). League organizers will form teams base on this buddy list and your skill level.

Are you over 18 ?*

YesNo

Guardian / Parents Names*

First NameLast Name

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Primary Phone*

E-mail*

Important Notes

· Dress appropriately. (Gym shoes/clothes)

· Be respectful to all staff, refs, and coaches

· Keep the gym clean.

· The league organizers reserve the right to form the teams to ensure the talents of all teams are balanced.

· Fee: FREE! We will be implementing cultural diversity, conflict resolution, mental health and trauma therapy workshops/surveys.

Emergency Contact & Health Insurance Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Emergency Phone*

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

YesNo

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 424 athlete factory, The P.r.o.m.i.s.e. Group, city of Pittsburgh and/or the persons involved with the program.

I have read and agree to the above conditions*

YesNo

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 gxtt.basketball@gmail.com.