Winter Skills Clinic Registration Form

Winter Skills Clinic Registration Form
Athlete Information
Player Name*

First NameLast Name
Guardian / Parents Names*

First NameLast Name
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Cell Phone
E-mail*
example@example.com
Basketball skill level*

1

2

3

4

5

1 is Begginer, 5 is Advanced
Important Notes

· Dress appropriately.

· No food or drink in the gym.

· Keep the gym clean.
Emergency Contact & Health Insurance Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
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:
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
Release of Liability

Although the safety of all sport activities is the primary concern, indoor sport activities at Sport Center'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 Sport Center and the persons in charge.
I have read and agree to the above conditions*

YesNo
Confirmation E-mail*
example@example.com

My Products

Session 1- 1/8, 1/15, 1/22

$90.00

Session 2- 2/12, 2/19, 2/26

$90.00

Both Sessions($180.00 Value)

$150.00

Total

$0.00

Payment Method
Credit	Express

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Signature*

Clear
Should be Empty:

Winter Skills Clinic Registration Form

Release of Liability