Texas Trail Blazer Basketball Organization

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Player Registration Form

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

* Home Phone:

* Birthdate:

* Email:

* Gender:

* Grade:

PARENT/GUARDIAN #1

* First Name:

Last Name:

EMail:

Home Phone:

Cell Phone:

PARENT/GUARDIAN #2

First Name:

Last Name:

Email:

Home Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact:

* Phone:

* Relationship to Player:

Insurance Carrier:

Policy #:

TTBBO WAIVER INFORMATION

In consideration of permitting the above named participant(s) to enroll in and participate in practices, leagues, tournaments, camps and clinics, outings and fundraising events sponsored by TTBBO, the Undersigned hereby voluntarily releases, discharges, waives and relinquishes any and all actions or causes of action for personal injury (including death) or property damage occurring to him/herself arising in the event of accident or injury to myself, my spouse or any child of mine (specifically including my child named above as the "Participant") or in the event of illness of myself, my spouse or any child of mine while in, on or about the premises of the TTBBO Events, or while participating in any activity sponsored by or under the auspices of the TTBBO under circumstances where I am physically unable to consent or am not present:

1. I hereby voluntarily consent to the furnishing to my said children of such medical care, attention and treatment by any hospital, physician or physicians as such hospital, physician or physicians may deem necessary or advisable.

2. I authorize any officer or member of the TTBBO to consent to such medical care, attention or treatment.

3. I agree to pay the reasonable cost of such medical care, attention or treatment and to indemnify and hold free and harmless of and from any and all liability for such cost the TTBBO and its officers and members thereof.

I, the undersigned, do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis or procedure rendered under the general or specific supervision of any member of the medical staff or of a doctor licensed under the provisions of the State Law and/or Public Health of the State and on the staff of any hospital holding a current operating certificate issued by the State Department of Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to render care which the aforementioned physician in the exercise of his best judgment may deem advisable. It is understood that effort shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. The Undersigned has read this document and is fully aware of the legal consequences of signing it. I, as the parent or guardian of the participant, acknowledge that I have read this Waiver, Release, Assumption of Risk and Indemnity Agreement and sign it on behalf of the participant with full knowledge and understanding of its contents.

I/we agree with the above *

Signature:

Date:

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Player Registration Form