Basketball Contest Registration Form

AKRON VERIFIED BASKETBALL TRYOUTS

APRIL 6 2024

3PM-5PM

SPRING/SUMMER 2023

(GRADES 9TH AND 10TH )

1570 Creighton Ave,

Akron, OH 44310

Athlete Information

Player Name

First NameLast Name

Players Age

Other

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

Basketball skill level

	1	2	3	4	5

1 is Begginer, 5 is Advanced

SCHOOL ATTENDED

Important Notes

· Dress appropriately.

· No food or drink in the gym.

· Keep the gym clean.

Emergency Contact & Health Insurance Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Do you have health insurance ?

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 Steele Academy 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 Steele Academy and Akron Verified.

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 gxtt.basketball@gmail.com.