Youth Basketball

S.U.N. X Dean Scott Dewey Development Sessions!

Athlete Information

Player Name*

First NameLast Name

What age is your child?

What grade is your child in? Number*

What school does your child attend? Type a label

Guardian / Parent Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Home Phone*

Area CodePhone Number

Cell Phone

Area CodePhone Number

E-mail*

Basketball skill level*

	1	2	3	4	5

1 is Beginner, 5 is Advanced

Emergency Contact & Health Insurance Information

Emergency Contact Name*

First NameLast Name

Relationship to emergency contact*

Phone Number*

Area CodePhone Number

Insurance Carrier*

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

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

Household Income*

Under $30,000$30,000 - $50,000$50,000 - $75,000Greater than $75,000

Release of Liability Although the safety of all sport activities is the primary concern, indoor sport activities at Sportsplex 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 CITS Foundation inc and Sportsplex. I allow Candles In The S.U.N. the right to capture and publish photos and videos for the organizations use.

I have read and agree to the above conditions*

YesNo

Confirmation E-mail*

Signature*

Signature

After completing this form, please click Submit Form. You will receive a confirmation notification. That means you're successfully registered. If you do not receive the notificaiton immediately, please contact us at DSingletary@CandlesInTheSUN.com.