Braveheart Athletic Association Athlete Registration Form

Braveheart Athletic Association Athlete Registration Form

Complete this form to register for athletic activities and provide necessary information.
Athlete Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Sport Registering For
Season
Parent/Guardian Information
Parent/Guardian Name

First NameMiddle NameLast Name
Relationship to Athlete
Email Address
example@example.com
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Adaptive Needs & Medical Information
Disability Type

Other
Mobility Assistance Needed?
Communication Assistance Needed?
Behavioral Support Needed?
Allergies
Medications
Medical Conditions
Physician Name
Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Provider
Policy Number
Emergency Instructions
Liability Waiver
I understand that participation in athletic activities involves risks including but not limited to injury, illness, permanent disability, and death. I voluntarily assume these risks on behalf of myself and/or my child. I release Braveheart Athletic Association, its directors, coaches, volunteers, sponsors, and affiliates from liability arising from participation in league activities except where prohibited by law.
I have read and agree to the Liability Waiver.
Parent/Guardian E-Signature
Date Signed

MonthDayYear
Date
Medical Authorization
I authorize Braveheart Athletic Association representatives to obtain emergency medical treatment for my child if I cannot be reached.
I authorize emergency medical treatment.
Parent E-Signature
Date

MonthDayYear
Date
Photo & Media Release
I grant permission for Braveheart Athletic Association to use photographs, videos, interviews, and recordings of the athlete for promotional, fundraising, website, social media, and educational purposes.
Media Permission
Parent E-Signature
Date

MonthDayYear
Date
Parent Code of Conduct
Parent Code of Conduct Agreement Checkboxes
Parent E-Signature
Date

MonthDayYear
Date
Payment
Registration Fee and Add-ons
prevnext( X )
Soccer Registration
Registration fee

$150.00

Donation to Scholarship Fund
Optional donation amount

$10.00

Total

$0.00
Payment Processor
Thank you for registering with Braveheart Athletic Association. Your registration has been received. A confirmation email has been sent to the address provided.
Scholarship Request (conditional bonus section)
Would you like to apply for financial assistance?
Household size
Brief explanation of need
Requested scholarship amount
Should be Empty:

Braveheart Athletic Association Athlete Registration Form

Athlete Information

Parent/Guardian Information

Adaptive Needs & Medical Information

Liability Waiver

Medical Authorization

Photo & Media Release

Parent Code of Conduct

Payment

Registration Fee and Add-ons*

Scholarship Request (conditional bonus section)

Registration Fee and Add-ons