5280 Hoops Registration Form

Are You interested in playing *

Fall

Winter

Spring/Summer

Player's Name *

Player's Name

First Name Last Name

First Name

Last Name

Player's Date Of Birth *

Player's Date Of Birth

MM DD YYYY

YYYY

Player's Grade *

What grade is the player currently in?

Player's Address *

Player's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Player's Email *

Player's Phone *

Player's Phone

(###)

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Parent's Names *

Home Phone

(###)

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Mother's Phone Number

(###)

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Mother's Email

Father's Cell Number

(###)

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Father's email

Emergency Contact *

Emergency Contact

First Name Last Name

First Name

Last Name

Emergency Contact Phone *

Emergency Contact Phone

Emergency Contact Phone Number

(###)

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Player’s Physician Name: *

Player’s Physician Name:

First Name

Last Name

Physicians Phone Number: *

Physicians Phone Number:

(###)

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Any Medical Concerns

AAU Insurance Information: Does the player have Health insurance? *

Yes

PERMISSION TO PLAY, RELEASE OF LIABILITY, AND CONSENT FOR MEDICAL TREATMENT THIS IS TO CERTIFY THAT MY CHILD HAS PERMISSION TO PARTICIPATE IN 5280 Hoops Basketball Club. It is understood that participation in this sport activity could result in injury to my child. The undersigned expressly assumes any such risks and waives and releases the 5280 Hoops Basketball Club, its directors, officers, coaches, referees, and any other volunteer or employee from any and all claims or causes of action or liability he/she or the child may have as result of negligence, breach of warrant, or otherwise. I give my consent for all emergency medical care prescribed by a licensed physician or dentist for the player identified in this registration. Care may be given under whatever condition necessary to preserve life, limb, or well-being of my dependent. _______________________________________________________________________ *

By Entering My Email Below I agree to the above statement and release 5280 Hoops Basketball Club and their represenatives from any liablity