Madison Magic Basketball Evaluation Registration Form

Madison Magic Basketball

5th Grade Boys' Evaluations

Wednesday March 20th 7:00pm - 8:30pm

&

Friday March 22nd 6:30pm - 8pm

Registration Form

Midvale Baptist Church

Athlete Information

Player Name*

First NameLast Name

Player Date of Birth*

Date

Guardian / Parents Names*

First NameLast Name

Relationship

Guaridan / Parents Names

First NameLast Name

Relationship

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Home Phone*

Area CodePhone Number

Cell Phone

Area CodePhone Number

E-mail*

E-mail

example@example.com

Estimated BB skill level*

	1	2	3	4	5

1 is Begginer, 5 is Advanced

Please bring a check for $50 made out to Madison Magic Basketball.

Emergency Contact & Health Insurance Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Do you have health insurance ?

YesNo

Insurance Carrier

Name of Policy Holder

Subscriber ID/Group Number

Card Number / Card Date

Does you have any allergies, chronic illness, or medical conditions that would limit high level activtiy?*

YesNo

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

Area CodePhone Number

Release of Liability

Although the safety of all sport activities is the primary concern, indoor sport activities 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 Madison Magic Basketball and the persons in charge.

I have read and agree to the above conditions*

YesNo

Confirmation E-mail*

Signature*

After completing this form, please click Submit Form. You will receive a confirmation email. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at julie@bartellnet.com.