Deer Park Youth Athletics

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DEER PARK YOUTH BASKETBALL FORM

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Birthdate:

Email:

Gender:

Grade:

PARENT/GUARDIAN #1

Firstname:

Lastname:

EMail:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

WAIVER INFORMATION

I, parent, grandparent, guardian hereby grant permission to participate in the youth athletic program for this upcoming season. By signing and submitting this contract, the participant and parent, grandparent, guardian hereby assume full responsibility and understand all risks associated with playing sports, including sprained or broken ankles and wrists, cuts, bruises, pulled muscles, etc., while performing the skills of the sport or any other activity associated with playing the sport. Also, the participant and parent , grandparent, guardian are responsible for any and all damages, losses, or injuries that he/she may incur, while attending or participating in the program and hereby expressly waiver any and all claims or causes against DEERPARK YOUTH ATHLETICS, including their board members, coaches, and sponsors.

I/we agree with the above *

I, PARENT, GRANDPARENT, GUARDIAN (circle one) hereby consent to the publication and use of my child’s likeness in a photograph for the purpose of promotion, publicity, advertising or other manner or media by DEER PARK YOUTH ATHLETICS.

Does the above participant have any special conditions, illness, or disorders that would prevent him/her from participating in this program? If YES please explain:

Please Explain:

All equipment, game uniform, and socks will not be issue until all balance is paid in full.

There is NO REFUND unless it's approved by the Board.

* indicates required fields

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DEER PARK YOUTH BASKETBALL FORM