BASKETMINDS Registration

BASKETMINDS Registration
Athlete Information
Player Name*

First NameLast Name
Are you over 18 ?*

YesNo
Guardian / Parents Names*

First NameLast Name
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
Who are your favorite players to play with?
Important Notes

· Dress appropriately; Wear athletic/basketball shoes only

· Do not eat before training

· Be 15 minutes early

- Work Hard and Have Fun
Emergency Contact & Health Insurance Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Do you have health insurance ?

YesNo, I'll pay with cash.
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?*

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
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
Signature*

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BASKETMINDS Registration

Release of Liability