Basketball League Registration Form

2025 Boys & Girls Club of Henderson

3x3 Youth Basketball League
Athlete Information
Athlete's Name

First NameLast Name
Athlete's Gender
School
Grade
Shirt Size
Guardian / Parents Names

First NameLast Name
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Would you be interested in coaching?
If yes, please send a text to (270)577-5523
Release of Liability

Although the safety of all sport activities is the primary concern, indoor sport activities at Cliff Hagan Boys & Girls Club'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 Cliff Hagan Boys & Girls Club and the persons in charge.
I have read and agree to the above conditions
Please Initial

Membership Card
Club Member Name

First NameLast Name
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Member Gender
Member Ethnicity
Family Setting
Household Type

Other
Number of People in Household
Member's School
Grade
Does your child qualify for Free or Reduced Lunch Program?
Household Income Level
Are any parents/guardians actively serving in the US Military? (Reserves Included)
Medical Information

The following questions will ask about your child's medical history and outline the Cliff Hagan Boys & Girls Club's medication policy.
Has your child been diagnosed with or suffer from any of the following?
Does your child currently take any medication? If so, please list the medication(s) below.
Member Physician Name
Member Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact/Primary Pickup Information

The following questions will ask parent/guardian emergency contact information. Please ensure the number(s) listed are active, working numbers. It is sole responsibility of the parent/guardian to notify the Cliff Hagan Boys & Girls Club if contact numbers, home addresses or any other important information changes. PLEASE NOTE THAT ONLY EMERGENCY CONTACTS LISTED ON THIS FORM WILL BE ADDED TO YOUR CHILD'S AUTHORIZED PICK-UP LIST. IF MORE ADULTS NEED TO BE ADDED TO THE AUTHORIZED PICK-UP LIST, PLEASE NOTIFY THE CLIFF HAGAN BOYS & GIRLS CLUB IMMEDIATELY.
Parent/Guardian #1 Name

First NameLast Name
Parent/Guardian #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #1 Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #1 Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #1 Email
example@example.com
Parent/Guardian #1 Employer
Parent/Guardian #2 Name

First NameLast Name
Parent/Guardian #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian #2 Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian #2 Employer
Parent/Guardian #2 Employer
Emergency Contact #1 Name & Relationship to Child (Other than individual s listed above)
Emergency Contact #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2 Name & Relationship to Child (Other than individual s listed above)
Emergency Contact #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #3 Name & Relationship to Child (Other than individual s listed above)
Emergency Contact #3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Liability Statement: "I hereby give my permission for the above youth to become a member of the Cliff Hagan Boys & Girls Club, INC. I understand that all precautions for safety will be taken, and that I will not hold the Cliff Hagan Boys & Girls Club or its officers responsible for any accidents while on the Club premises or while engaged in any of the Club's activities away from the facility. If necessary and I cannot be contacted, I hereby authorize Club personnel to obtain emergency medical care for my child. I understand that the Club is not responsible for the time or manner in which the Club member may arrive or leave the Club. I understand that the Cliff Hagan Boys & Girls Club will not be held responsible for loss or theft of personal property. Furthermore, I give my consent for any photographs or videos in which the above member may appear to be used for marketing/public relations purposes in any way the Club may choose to use them.
Field Trip Permission: I give the above member permission to participate in any field trips offered through the Cliff Hagan Boys & Girls Club during Club programming hours, both regular and extended hours. I understand that the member's participation in this activity is dependent on several factors including behavior, Club participation, and discretion of Club staff. Agreeing to this statement does NOT ensure participation on any given trip. I understand that only field trip transportation will be provided, and parents/guardians will be responsible for transportation to and from the Cliff Hagan Boys & Girls Club.
Acceptable Use Policy: An Acceptable Use Policy defines appropriate use of computer equipment and the internet for both staff and members, as approved by the Board of Directors and signed by each staff member and placed in their membership file. Responsible Computer Use Guidelines for Members Boys & Girls Clubs’ (“Club” or “Clubs”) computer network and internet access are available to members to enhance their educational experience and help them become literate in an increasingly technological world. The purpose of this Acceptable Use Policy is to foster the appropriate use of that network, email and the internet. The following guidelines apply to all users, whenever they access any of the Clubs’ network connections. Educational Purpose: The Clubs’ network has been established for educational purposes limited to classroom activities, school-to-career development and scholastic research on appropriate subjects. The Clubs’ network has not been established as a public access service or a public forum. The Club has the right to place reasonable restrictions on the material members access or post through the system. Members are expected to follow this Acceptable Use Policy (as well as other Club rules and policies applicable to members) when in the Technology Center or accessing the network. The Clubs’ network is considered a limited forum, similar to a school and, therefore, the Club reserves the right to regulate that forum for valid educational reasons. The Club will not restrict speech on the basis of a disagreement with opinions you, the members, are expressing. You should expect only limited privacy with the content of your personal files on the Clubs’ network. This situation is similar to the rights you have in the privacy of your locker at school. The Club reserves the right to search your files, if there is a reasonable suspicion you violated this Acceptable Use Policy, Club rules and policies, or the law. Unacceptable Uses and Personal Safety: You must not post personal contact information about yourself or other people. Personal contact information includes (but is not limited to) home, school or work addresses; telephone numbers; and email addresses. You must never agree to meet with someone you have met online without your parent’s approval. A parent or guardian should always accompany you to such meetings. You must promptly disclose to a Club staff member any message you receive that is inappropriate or makes you feel uncomfortable. Illegal Activities: You must not attempt to gain unauthorized access to the Clubs’ network, or to any other computer system through the Clubs’ network. This includes attempting to log in through another person’s account or accessing another person’s files. These actions are illegal, even if only for the purpose of “browsing.” You must not make deliberate attempts to disrupt the computer system or destroy data by spreading computer viruses. You must not use the Clubs’ network to engage in any illegal act, including, but not limited to, arranging for the purchase or sale of alcohol, tobacco or other drugs; engaging in criminal activity; or threatening the safety of another person. System Security: You are responsible for your individual user account and should take all reasonable precautions to prevent others from being able to use your account. Under no circumstances should you provide your password to another person. You must immediately notify a Club staff member if you have identified or witnessed a possible security problem. Do not look for security problems, because this may be construed as an illegal attempt to gain access. Inappropriate Use: Restrictions against inappropriate use apply to public message, private message and material posted on web pages. Within reason, freedom of speech and access to information will be honored. The following are not permitted: • Sending or displaying unkind or offensive messages or pictures, pornography or hate literature • Using unkind or obscene language • Harassing, insulting or attacking others • Intentionally damaging computers, computer systems or computer networks • Violating copyright laws • Using another person’s password • Trespassing into another person’s folders, work or files • Intentionally wasting limited resources (i.e., distributing mass email messages, participating in chain letters, creating or participating in unauthorized newsgroups, and storing files on file servers without proper authorization) • Employing the network for commercial purposes, political activities or lobbying • Installing additional software without prior approval • Using portal or proxy websites Violations may result in the loss of access, as well as other disciplinary or legal action. Respect for Privacy: You must not re-post a message that was sent to you privately, without the permission of the person who sent the message. You must not post private information about another person. Plagiarism and Copyright Infringement: You must not plagiarize works you find on the internet. Plagiarism is taking ideas, writing or pictures of others and presenting them as your own. It is dishonorable, and it is a prohibited use of this facility. You must respect the rights of copyright owners. Copyright infringement occurs when you reproduce a work that is protected by a copyright without authorization. If a work contains language that specifies appropriate use of that work, you should follow the expressed requirements. Copyright law can be confusing; therefore, if you have any questions, please ask a teacher or Club staff member. Disciplinary Actions: Members who violate the Acceptable Use Policy may be denied future internet and/or network privileges for a defined period of time and may be subject to other disciplinary measures as set forth by Club policies. By signing below, I agree that I have read, understand and will abide by these regulations.
Signature
Payment Information:

3x3 Youth Basketball League Price: $45.00 + 3% Service Fee
Payment
prevnext( X )
3x3 Basketball League
$45.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00
Should be Empty:

2025 Boys & Girls Club of Henderson

Release of Liability

Membership Card

Medical Information

Emergency Contact/Primary Pickup Information

Payment Information:

Payment*

Payment