Dream Epic Foundation Gorillas Basketball Registration Form

Dream Epic Foundation Gorillas Basketball Registration Form
Athlete Information
Player Name

First NameLast Name
Player Grade - Age

GradeAGE
1 Guardian / Parents Names

First NameLast Name
Cell Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
2 Guardian / Parents Names

First NameLast Name
Cell Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Basketball skill level

1

2

3

4

5

1 is Begginer, 5 is Advanced
type in 3 possible jersey numbers, as well as jersey size
Important Notes

· Dress appropriately.

· Keep the gym clean.

. Must be at practice and games on time

. Bad behavior or sportsmanship is not tolerateted
Emergency Contact & Health Insurance Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Do you have health insurance ?
Insurance Carrier
Name of Policy Holder
Subscriver ID/Group Number
Card Number / Card Date
Does you have any allergies, chronic illness, or medical conditions that would limit high level activtiy?
Please describe
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
Format: (000) 000-0000.
PLEASE PROVIDE A COPY OF YOUR CHILDS BIRTH CERTIFICATE UPON FIRST PRACTICE OR TRAINING SESSION!!
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
Confirmation E-mail
example@example.com
Signature
Should be Empty:

Dream Epic Foundation Gorillas Basketball Registration Form

Release of Liability