Willis Little Dribblers

Willis Little Dribblers
Athlete Information
Player Name

First NameLast Name
Boy or Girl?
Grade as of Sept 1, 2024
What school in district does player attend?
Basketball skill level

1

2

3

4

5

1 is Beginner, 5 is Advanced
Guardian / Parents Names

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Contact & Health Insurance Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Do you have health insurance ?
Insurance Carrier
Name of Policy Holder
Subscriver ID/Group Number
Card Number / Card Date
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 the proper facility for treatment.
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
Format: (000) 000-0000.
Release of Liability

Although the safety of all sport activities is the primary concern, indoor sport activities at Willis ISD 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 Wills ISD, IHOOP 365, and the persons in charge.
I have read and agree to the above conditions
Confirmation E-mail
example@example.com
Signature
Payment is due at the time of registration. $85 Multi-child discount -$5 per additional in same household.

CASHAPP:$iHOOP365TX

VENMO:@iHOOP365TX

CASH/CHECKS: Text 936.662.1287 to arrange meeting to pay fees. Registraton is not complete until paid.
Should be Empty:

Willis Little Dribblers

Release of Liability