Basketball

Leeds Youth Basketball
Parent or Guardian Information
Parent or Guardian Name*

First NameLast Name
Parent or Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent or Guardian Phone Number*
Please enter a valid phone number.
Coaching Interest*
Parent or Guardian Email*

Confirmation Emailexample@example.com
Emergency Contact
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Player Information
Player's Name*

First NameLast Name
Male or Female*
Player's Preferred Name*
This could be a nickname, etc.
Player's Allergies, Medical Problems and/or Medications
Describe Player's Allergies, Medical Problems and/or Medications
Division

Basketball / Ages 5-12
Team Type
Ages
Is the player on a school team?*
If the player is 13-14 years old, which school?*
Player's birthday*

MonthDayYear
Date
Player's age as of September 1st of the current year*
Returning Player*
If a returning player, please provide previous Coach's name*
NOTE: Indicating previous coach's name does not guarantee the same placement this season. It's just helpful information!
Preferred jersey number*
NOTE: Indicating preferred jersey number does not guarantee the same jersey number from last season. We will make every effort to match preferences.
By clicking the Submit button below, I (we), the parent/guardian(s) of the above registered player do hereby release, acquit, hold harmless and forever discharge the Leeds Youth Athletic Association (LYAA), district, its Board of Directors, authorized representatives and volunteers from any accidents or injury that may occur.

I understand that the LYAA insurance is secondary coverage to our primary insurance. I (we) hereby authorize said district, and its authorized personnel to obtain for said player, emergency treatment for sudden injury or illness in the event of our absence.

I grant the LYAA, its’ representatives and employees, the right to take photographs and video of me and my property in connection with the above identified player. I further authorize the LYAA, its’ assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree, the LYAA may use such photographs and video for the use of promoting the LYAA in advertising, websites and social media.

We will not sell or share your information outside of the LYAA, district, Board of Directors, authorized representatives and/or volunteers.

I (we) further understand that it is my (our) responsibility to select the player’s uniform size and if I (we) select the wrong size, I (we) are responsible for purchasing the additional size(s) needed. This applies to online and in person selections.

Waiver: Please understand registering online DOES NOT allow one to bypass an in-person sizing visit. Every player MUST physically be sized for a uniform. If a player is not physically sized for a uniform and the size is given to the park verbally, understand that a uniform that doesn’t fit is the parent/players responsibility and NOT the responsibility of the park. The park will not be financially responsible for a replacement.

Payment Information

BasketballPrice includes, registration, web and transaction fees

$166.40 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Leeds Youth Basketball

Parent or Guardian Information

Emergency Contact

Player Information

Division