Norrisville Recreation Council - (White Hall, MD)

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Norrisville Recreation Basketball Registration Form

PLAYER INFORMATION

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Home Phone:

* Birthdate:

* Email:

* Gender:

Age Group::

* Select Shirt Size:

PARENT/GUARDIAN #1

* Firstname:

* Lastname:

* Email:

* Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

Are there physical conditions or allergies of which the coach/administrator should be aware?:

Are special accommodations needed?:

WAIVER INFORMATION

I certify that the individual named above is in good physical condition and is capable of participating in the named program. If medical attention beyond first-aid treatment is required, I understand that every attempt will be made to contact me at the emergency number provided. If contact with me is not possible, I give permission for medical attention to be administered. Furtermore, I hereby release, exonerate and discharge the organizers, officers, volunteers, coaches, officials, representative, employees, and agents from any and all actions and for any injuries or damages incurred while participating in, or traveling to and from, this program.

In accordance to Maryland law, I hereby acknowledge that I have received the information regarding concussions published by the United States Department of Health and Human Services Centers for Disease Control and Prevention (CDC). For additional information I understand that I may call 1-800-232-4636 or go to www.cdc.gov/concussion/HeadsUp/youth.html.

I/we agree with the above *

Please visit our website for more information on cardiac arrest.

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