Wild West Basketball Club

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Player Registration Form

PLAYER INFORMATION

* Student-Athlete:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Home Phone:

* Birthdate:

* Gender:

* School:

* 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 #:

WILD WEST BASKETBALL CLUB CONSENT,RELEASE, & WAIVER

I hereby attest that I am are fully congnizant of the risks involved in the sport of basketball and voluntarily assume and agree to abide by the published and spoken rules of Wild West at all times during my child's participation. I acknowledge and fully understand that my child will be engaging in a contact sport that might result inserious injury or death, due to or not due to my child's actions. I will report any injury or medical condition prior to any game or practice. I authorize and consent to reasonable and immediate medical treatment/first aid at practice and games. In the event of any major medical emergency and/or transportation to a medical facility, my private medical insurance will be used. I assume all liabilities and release,waive, and discharge and covenant to sue Wild West Basketball Club, its administrstors,employees, coaches, assistant coaches,associates,schools,school districts, or school staffof any kind of incidental or direct liability,claims, and legal actions due to injury,damage,expense of any kind arising form or connected with my child's participation in the Wild West Basketball Club Program(past,current,or future). I have read and understand, and will adhere to the "Program Info" and " Code of Conduct" information.

I/we agree with the above *

* indicates required fields

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