LASAR/Mainland Youth Basketball

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Mainland Basketball Reg. Form

PLAYER INFORMATION

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Home Phone:

* Birthdate:

* Email:

* Gender:

* Grade:

PARENT/GUARDIAN #1

Volunteer:

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

RELEASE/HOLD HARMLESS:
I/we being the parents or guardians of the above named child hereby gives permission and approval for him/her to participate in any and all basketball activities including, but not limited to practices, scrimmages and games of the Linwood All Sports and Recreation (LASAR). I/we assume all the risks and hazards incidental to such participation including but not limited to practices, scrimmages, games and transportation to and from the games or other activities. I/we also agree to waive, release, absolve, indemnify and hold harmless Linwood All Sports and Recreation (LASAR) and the officers, board members, coaches, referees and other personnel involved with said organization against all loss or damage for any claim arising out of any injury to my child while participating in the basketball program.

I/we agree with the above *

* indicates required fields

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

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Mainland Basketball Reg. Form