Collingdale Athletic Club - (Collingdale, PA)

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2024/2025 Basketball Clinic - Ages 5 & 6 (boys & girls)

Player Information -- Clinic is for boys and girls basketball. Starts January 2024.

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Primary Phone:

* Grade:

Email:

* Gender:

* Shirt/Jersey Size - if not sure go up a size:

Youth Extra Small

Youth Small

Youth Medium

Youth Large

Youth Extra Large

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

I hereby certify that I am the parent or legal guardian of the child, and as such, give my permission for him/her to participate in the athletic program and sports events of the Collingdale Athletic Club for the current member year. I further certify that he/she is physically able to participate in the Club’s programs without detriment to his/her health. I understand that the club does not provide insurance coverage, and I assume the risk of injury and possible medical expenses as my individual responsibility. I also understand and appreciate the risks involved in the athletic program and in transportation to games and any other Club activity. When I do not provide transportation for him/her, the Club has my permission to assign him/her to a volunteer driver. On behalf of myself, my spouse and my child, we forever release and discharge the Collingdale Athletic Club, its employees, agents, coaches and volunteers of and from all claims, actions suits, demands or judgments arising from any accident, injury, loss or expenses whatsoever.

I agree to return at a time and place set be the Club, any uniforms and equipment issued to him/her, cleaned and mended, and in as good a condition as received, except for normal wear. I hereby agree and promise that in the event my child fails to return, loses, damages or destroys any and all athletic equipment or any property owned by, leased, or in the possession of the Collingdale Athletic Club, I shall reimburse (PAY) and contribute in full, the replacement or repair cost of said property to the Collingdale Athletic Club.

I/we agree with the above *

* Enter your email address again to consent to waiver above.:

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REGISTRATION($40) *