Basketball 2021 - Epuerto Sports - Soccer, Track and Field, Basketball, Volleyball, Teqball

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PARTICIPANT REGISTRATION

Name*

Mailing Address*

Street Address City State ZIP Code

Home Address*

Street Address City State ZIP Code

Phone*

Emergency Phone*

Gender*

Male
Female

Shirt Size*

School Presently Enrolled*

Grade*

If enrolled in Middle School/Jr.-Hi, Last Elementary School Attended

Has child participated in Boys & Girls Club Program during the year*

Yes
No

MEDICAL

Does child have any Medical Problems?*

Yes
No

If yes, Please Explain

Child’s Physician

Phone

PARENT INFORMATION

Father’s Name*

Father's Employer

Father's Phone*

Mother’s Name*

Mother's Employer

Mother's Phone*

Email*

COMMENTS

Add your comments here

PERMISSION TO PLAY

As the parent or legal guardian of the child named above who is registered to participate in Boys & Girls Club activities for the current season, I hereby acknowledge to the Boys & Girls Club that I am not aware of any medical or other reason why my child should not be allowed to participate in Boys & Girls Club activities. In the event of accidental injury incurred while participating in Boys & Girls Club activities, I authorize Boys & Girls Club representatives to secure medical care for my child in the event I cannot be reached. Acting on my own behalf and on the behalf of my child as his/her parent or as his/her guardian, I hereby release Boys & Girls Club and its agents, staff, representatives, directors, coaches and anyone else acting on behalf of Boys & Girls Club activities, from any and all liability for any injury or condition resulting from his/her participation in Boys & Girls Club activities. I agree to reimburse the Boys & Girls Club at replacement cost for any uniform and/or protective equipment issued the child if said items are not returned within 30 days follow- ing the last date of the activities registered for herein and/or are damaged due to neglect. If Boys & Girls Club is required to seek collection and/or reimbursement of uniform and/or equipment by legal action, I further agree to pay all court costs and legal fees.

Permission to Play Agreement*

I agree

Donation

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Total

$0.00

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