Bensalem Chargers Travel/AAU Basketball Academy

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Chargers Winter Tryout/Registration Fee

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Birthdate:

Email:

Gender:

Grade:

School:

PARENT/GUARDIAN #1

Firstname:

Lastname:

EMail:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

Would you like to be an assistant coach?:

Would you like to be part of fundraising committee?:

Would you be willing to help with concession stand?:

Would you be interested in being a "team mom":

Would you like to help do scoreboard / scorebook?:

As parent or guardian of the above named child I agree to indemnify and save harmless Bensalem Chargers, and all affiliates hosting summer league games, their coaches, advisors or employees from and against all loss or expense (including costs and attorney's fees) by reason of liability imposed by law upon the organizations for damages because of bodily injury, at any time, incurred by the above named child while he or she is participating in summer basketball, related activities or on account of damage to property including loss of use thereof arising out of or in consequence of the use of any Bensalem Chargers and affiliate facilities, whether such injuries to persons or damage to property is due to or claimed to be due to the negligence in whole or in part of the organization, Bensalem Chargers and affiliate schools hosting games or coaches, advisors or employees. The undersigned parent or guardian hereby acknowledges that he or she has or will provide appropriate Health and Accident Medical Insurance to cover the above named child against any and all personal injuries sustained while a participant in any activity sponsored by Bensalem Chargers

*** Insert your waiver information here ***

I/we agree with the above *

* indicates required fields

Tryout Fee($25)

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Chargers Winter Tryout/Registration Fee