Brisbane Warriors Basketball Club

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Brisbane Warriors AAU Registration Form

PLAYER INFORMATION

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

Home Phone:

* Birthdate:

Email:

* Gender:

* Grade:

PARENT/GUARDIAN #1

* Firstname:

* Lastname:

EMail:

Home Phone:

Work Phone:

* Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact:

* Phone:

* Relationship to Player:

* Insurance Carrier:

Policy #:

WAIVER INFORMATION

*Awknowledging of this release agreement shall be considered a waiver of any claim for such injury or loss.
*Awknowledging this release agreement authorizes all coaches and volunteers of Brisbane Warriors to obtain medical treatment and services for their child or ward when parent(s) or guardian is not present and agree to pay the fees and costs of such treatment and services.
*Awknowledging of this release agreement means the parent(s) or legal guardian shall be responsible for any damages caused by their child or player(s) to the gyms.

I/we agree with the above *

Signature:

Date:

Signature:

Date:

* indicates required fields

IMPORTANT: Online Payment with credit cards is not active for this form

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Brisbane Warriors AAU Registration Form