Eureka Youth Basketball
Player Name
Grade :
Gender
Parent or Legal Guardian Name:
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Name of person in case of an emergency: (secondary to parent/guardian)
Phone number of person in case of an emergency:
List all known allergies, Medications, or Activity Restrictions:
T-Shirt Size
Please Select
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
(Scholarships are available as needed. Please contact Eureka County Juvenile Probation for more information. No Child will be turned away)
As legal guardian of the named participant, knowing the risks involved, I give my permission for him/her to participate in all activities for said program. In addition, I authorize all instructors, directors, coaches, and assistants to obtain medical care for my son/daughter in the event that such is needed. Further permission is hereby granted to the licensed physician or accredited hospital and their associates to perform any medical and/or surgical procedures deemed essential to the treatment of the above-named participant. I further agree to be responsible for payment of such care.
Signature of Parent or Legal Guardian
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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