Sequim Youth Basketball Association 2013-14 Registration Fee: $45 per player Make checks payable to: Maximum $100 per family Sequim Youth Basketball Please complete a form for each child and bring to one of the evaluation/registration sessions or mail form and fee payment to: Sequim Youth Basketball PO Box 3395 Sequim, WA 98382 Player Information Last Name _______________________
First Name _____________________
Grade in School ____
City/State/Zip ______________________ School Attended _________________ Parent Information Circle a player shirt size. Youth Parent/Guardian Name(s): ____________________________ N/A Home Phone ____________ Other Phone ____________ Med. Large Email Address ____________________________ X-Lg.
Adult Small Med. Large X-Lg.
Medical Information Physician or Clinic: ____________________ Phone: ____________ Medical Plan Name: ____________________ Plan ID #: ____________________ Emergency Contact: _____________________ Phone: ____________ Does your child have any current conditions that limit his/her ability to run, throw, catch a ball, participate, or understand the rules of basketball? Yes ____ No _____ If yes please explain _______________________________________________________ Sequim Youth Basketball desires to provide a positive experience for kids. Please let us know if you could help. Circle as many as apply. Coach /Asst. Coach (pre-season training and background checks will be required) Referee
Sponsor a Team
Assurances: I/We, parent or guardian of the above named player hereby give approval for him/her to participate in any and all Sequim Youth Basketball activities including transportation. I/We know that participation in basketball may result in serious injuries to players. I/We do hereby waive, release organizers, sponsors, supervisors, participants, on persons transporting my/our child whether the result of negligence or any cause. In the event I cannot be reached for an emergency, I hereby give permission to Sequim Youth Basketball to hospitalize or secure treatment as needed for my child. In addition, I/We, parent or guardian of the above named player, acknowledge that I/We have been given and read the Concussion Information Sheet as required for participation by the Sequim School District.
Parent/Guardian Signature: _________________________ Date: _____________