Dearborn YMCA

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Dearborn YMCA Basketball Registration

PLAYER INFORMATION

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Cell Phone:

* Birthdate:

* Email:

* Gender:

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 #:

* Shirt Size:

Please select if you would like to:

Special Requests:

WAIVER INFORMATION

I hearby give my permission for my child or ward to participate in the specific activities described on this form. I understand that the activities are inherently risky and potentially hazardous, and as a result, I accept full responsibility for, and risk of, injury to my child or ward for loss or damage to his or her property that may result from his or her participating therein. I, for, and on behalf of myself and my child or ward, hereby release, waiver, and covenant not to sue the Dearborn YMCA, and its directors, officers, employers, and agents (collectively the "Releases") from all claims, demands, damages, losses, or causes of actions arising from any injury to my child or ward or lose or damage to his or her property that may occur while my child is participation in the activities. I further indemnify and hold harmless the Releases from all loss, liability, damage, or cost that may occur due to my child's or ward's participation in the activities.
In the event of injury, I authorize the Releases to provide or cause to provide such medical care and treatment to my child or ward as may be necessary and appropriate. I understand that I am solely responsible for all costs incurred for such medical care or treatment. I hereby give my permission to the Releases to use indefinitely, without limitation or obligation, photographs, film footage, or tape recordings which may include my child's or ward's image or voice for the purpose of promoting or interpreting the Dearborn YMCA programs and activities.
I have read and voluntarily signed this agreement and agree to be bound by its terms.

I/we agree with the above *

Signature:

Date:

* indicates required fields

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Dearborn YMCA Basketball Registration