Basketball Youth Registration Form

Participant Information
Athlete Name*

First NameLast Name
Gender*
Date of Birth*

MonthDayYear
Ages 2010-2021
Age*
Age based on date of birth
Proof of Age

Richmond Parks and Recreation accepts: a picture of a DMV ID card, school records, passports, or birth certificates.
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School Name*
Jersey size
Youth XS (4-5), Youth S(6-8), Youth M(9-10), Youth L(11-12).
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.

Parent/Guardian Consent
I, {name16} the undersigned parent/guardian, hereby grant permission for my child, {athleteName}, to participate in Team Ansars Recreation youth soccer programs and activities. I acknowledge that there are risks associated with soccer and hereby release and hold harmless Team Ansars, its officers, employees, and agents from any and all liability for any injuries or damages that may occur.
Parent/Guardian Consent*

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Date*

MonthDayYear
Date

Media Release Consent
I, {name16}, grant permission for photographs, videos, and/or other media recordings of my child, {athleteName}, to be used for promotional purposes related to the Team Ansars Recreation youth program.
Parent/Guardian Consent

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Date

MonthDayYear
Date

Additional Authorized Guardian Pickup
Authorized Guardian’s Name

First NameLast Name
Relationship to child
Authorized Guardian’s Phone
Please enter a valid phone number.
I, {name16}, hereby authorize the above-named individual to pick up my child, {athleteName}, from Team Ansars activities/events. I understand that the authorized individual will have to provide photo ID at pick up, that this authorization is valid until further notice and can be revoked by me at any time in writing.
Signature

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Date

MonthDayYear
Date

Registration Fee

Winter Basketball RegistrationThis fee covers: league fees, field rentals, refreshments, award

$80.00

Enter coupon

Total

$0.00

Credit Card

Apple Pay

Google Pay

Cash App Pay

ACH Bank Transfer