NEW ENGLAND REBELS BASKETBALL CLUB

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REBELS REGISTRATION FORMS

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Birthdate:

Email:

Gender:

School:

Grade:

Previous teams/Experience:

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 #:

I hereby agree to the above registrant's participation in the New England Rebels AAU Basketball club tryouts and hereby agree to hold the New England Rebels AAU Basketball Club, as well as all coaches, administrators, volunteers, and agents of the New England Rebels AAU Basketball Club harmless for any and all injury, loss or damage suffered by the above-named participant and his/her immediate family as a result of his/her participation in said program.

I/we agree with the above *

Signature:

Date:

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