OPTIMIST BASKETBALL
OPTIMIST CLUB OF GETTYSBURG
REGISTRATION FORM - BASKETBALL
_________________________________ ____________________________
PLAYER’S FIRST NAME PLAYER’S LAST NAME
Player requests to be on the same team as (only list one other player please or N/A)___________________________
SESSION: BOYS GIRLS PLAYED LAST YEAR: YES NO LAST YR’S TEAM COLOR:
GRADE: _______ SCHOOL:_______________________
T-SHIRT SIZE: Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult Extra-Large
GUARDIAN NAME(S): _______________________________ TELEPHONE #: ___________________
EMAIL (If you would like to subscribe to the Optimist email for updates): ____________________________________
PARENTS, WE COULD USE YOUR HELP
I would like to coach
COACH’S NAME: ___________________________
T-shirt Size: ______________________________
MEDICAL INFORMATION:
Does this child have any disabilities, allergies, hemophilia, heart condition, history of respiratory illness, present injuries or limitations, or any other significant medical condition? If yes, please list.________________________________________________________________ _____________________________________________________________________________________________________________
EMERGENCY AUTHORIZATION:
I, the undersigned, legal guardian of the participant, minor, hereby authorizes the coaches, assistant coaches or parents of team members acting in the capacity of activity supervisors as my Agents, to consent to medical, surgical or dental examination and/or treatment. In case of emergency, I hereby authorize treatment and/or care at any hospital. If there is an emergency and I cannot be reached please contact the person below, who is hereby authorized to act on my behalf:
NAME OF EMERGENCY CONTACT: TEL #:
WAIVER OF LIABILITY AND DISCLAIMER:
To induce the OPTIMIST CLUB OF GETTYSBURG to accept registration and permit participation by the named individual, I, the guardian of said individual, hereby give my consent and agree to release, indemnify, and hold harmless OPTIMIST CLUB OF GETTYSBURG, its coaches and representatives, and the GETTYSBURG AREA SCHOOL DISTRICT from any claim arising out of injury to the named individual.
SIGNATURE OF GUARDIAN: DATE:
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