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2010 PLAYER REGISTRATION AND MEDICAL RELEASE FORM
First Name:________________ MI:_____ Last Name_________________ D.O.B:_____/____/_____
Street Address: _________________________________________ Apt. #: ____________
City: ______________________ State: ________ Zip: __________ Gender M____ F____
Home Phone: (____) _________________ Cell Phone: (_____) ____________________
School: ___________________________ Grade: ___ Age as of March 1, 2010: ______
Prior basketball experience: None: _____ Team and/or League Name: ______________
If so, years? _____ Height (inches): _ _ Weight (lbs.) ____
Experienced Position(s) __________________
PARENT/GUARDIAN INFORMATION Name: ______________________________
Name: __________________________ Phone (if different) (______)_____________ Phone (if different) (______)____________ Work/Cell #: (______)__________________ Work/Cell #: (______)____________
Name(s) of other members of immediate family (or same household) registering this season:____________________________________
+MEDICAL INFORMATION+
Family Doctor/HMO _____________________________ Phone Number: (_____)_______________
Medical/Hospitalization Insurance Company: ________________________ Policy #: _____________
Medication Allergies: ________________________________________________________________
Other Allergies: ____________________________________________________________________
Player’s medical history that manager/coach may need to know, or other conditions or information that may be important in the event emergency medical care is needed: _____________________________
Emergency Contact : ___________________ Phone #: (______)____________________
1.
I, Parent or Guardian, of the above named registrant, hereby gives my approval of his/her participation in any and all PSPA activities during the current season. I acknowledge that his/her participation may result in serious injuries and protective equipment does not prevent all injuries to players.
I, Parent or Guardian, of the above named registrant, hereby gives my approval of his/her participation in any and all PSPA activities during the current season. I acknowledge that his/her participation may result in serious injuries and protective equipment does not prevent all injuries to players.2.I do hereby waive, release, absolve, indemnify, and agree to hold harmless PSPA, its President, organizers, coaches, referees, sponsors, contributors, participants, and persons transporting said registrant to and from PSPA activities from any claim arising out of injury or loss to said registrant except to the extent and in the amount covered by accident or liability insurance carried by YBOA, of which my child is registered.
I do hereby waive, release, absolve, indemnify, and agree to hold harmless PSPA, its President, organizers, coaches, referees, sponsors, contributors, participants, and persons transporting said registrant to and from PSPA activities from any claim arising out of injury or loss to said registrant except to the extent and in the amount covered by accident or liability insurance carried by YBOA, of which my child is registered.3.I agree that said registrant will abide by all policies, rules, and regulations of PSPA.
I agree that said registrant will abide by all policies, rules, and regulations of PSPA.4.I certify that said registrant meets all AAU/YBOA eligibility requirements and that I will provide a copy of his/her birth certificate and proof of legal residence (as defined by AAU/YBOA.) If requested to do so by Tournament officials. I further understand that the assignment of said registrant to specific teams and/or levels of competition are at the discretion of the President and coaches of PSPA.
I certify that said registrant meets all AAU/YBOA eligibility requirements and that I will provide a copy of his/her birth certificate and proof of legal residence (as defined by AAU/YBOA.) If requested to do so by Tournament officials. I further understand that the assignment of said registrant to specific teams and/or levels of competition are at the discretion of the President and coaches of PSPA.5.MEDICAL RELEASE: I hereby give my permission for a representative of PSPA to contact my family doctor and /or to take my child to the nearest hospital emergency room if I cannot be reached immediately. I further give the hospital and/or any attending physician permission to administer needed emergency medical treatment.
MEDICAL RELEASE: I hereby give my permission for a representative of PSPA to contact my family doctor and /or to take my child to the nearest hospital emergency room if I cannot be reached immediately. I further give the hospital and/or any attending physician permission to administer needed emergency medical treatment.Signature: _______________________________ Date: __________________________
Registration & Medical Waiver
