Elite Level Prep Youth Basketball League

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Youth Basketball Club

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Birthdate:

Gender:

Grade:

PARENT/GUARDIAN #1

Firstname:

Lastname:

Street:

City:

State:

Zip Code:

EMail:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Street:

City:

State:

Zip Code:

Email:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

WAIVER INFORMATION

I agree to defend, indemnify and hold harmless Elite Level Prep, any affiliated organization of Elite Level Prep, and their respective directors, officers, employees, volunteers, and representatives, and or legal representatives have or may have in the future, from and against any and all claims, injuries, liabilities, or damages arising out of or being related to my participation in Elite Level Prep Youth Basketball Club and Elite Level Youth Basketball League.

I/we agree with the above *

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