4th ANNUAL JUNIOR
BASKETBALL LEAGUE-AGES 13-16 Post Office Box 4028
SUBJECT: BASKETBALL
Consent and Registration Form (518) 209-8999
PERSONAL INFORMATION:
------------------------------------------ -------------------------------------- --------------------------------
Player’s Last Name Player’s First
Name Player’s Middle
Name
------------------------------------------------------------------------------ --( )--------------------------------
Player’s Address
Player’s Telephone No.
------------------------------------------ ---------------- --------/--------/-------------
SSN# Optional Age as of 01/01/06 Date OF Birth
----------------------------------- -----------
---------------------------------- ------------------- ----------------------
Street Address Apt# City
State Zip Code
-------------------------------------------------------------------- (
)--------------------------------------------------Name of Parent or
Guardian Telephone
Number
-------------------------------------------------------------------- (
)--------------------------------------------------Alternate Contact in
case of emergency Telephone Number
Medical
History:
Allergic
Reactions:_____________________________________________________________________.
Present
Medication:____________________________________________________________________.
Relevant
past/present treatment of
injuries:________________________________________________.
Publicity
Release Agreement: I,_____________________the parent/guardian
of_____________________
Hereby give the Thomas
Sports Group, Inc. permission to use my child’s image in photographs and video
recordings for sole purpose of publicizing the program. I understand that all
personal information will remain confidential, that these images will not be
sold or used in any commercial enterprise and that I reserve the right to view
said photographs/video prior to their public release.
Medical
Release: Participation in many sports
can result in physical injury. Injuries common to Basketball under normal
conditions include sprains, strains, contusions, fractures, dislocations,
ruptures, hernia ions, lacerations, concussions; and in isolated occasions,
even death has occurred. In the event of an injury, I do authorize qualified
personnel designed by the Basketball staff and their volunteers or designees to
administer first aid and/or care deemed necessary. We/I the undersign, for
ourselves, our heirs, executors and administrators waive, release and forever
discharge the Basketball staff and volunteers of and from any and all rights
and claims for damage to persons or property, while at the Calvary Tabernacle
Church gymnasium and surrounding properties at Calvary Tabernacle in
Schenectady, NY or while participating
in Basketball activities.
Parent/Guardian Signature: _____________________________________Date:___________________