Date: _________________ T-Shirt Size:____________

Player Last Name: ____________________

First Name: _________________

Date of Birth: _______________________ Grade: ________

Parents’ Name: __________________________________________________

Parents’ Cell Phone Number: _______________________________________

EMAIL ADDRESS: _________________________________________________

Emergency Contact & Phone: _______________________________________

JWBASKETBALL places the highest priority on safety and sportsmanship. Does your child have any medical conditions that prohibit him/her from participating in such basketball activities? YES NO

Any known allergies? YES NO

If YES, please explain:

We the undersigned,  legal parents or legal guardians of________________________verify that the minor player participant listed above is in good health and able to participate in this event. In addition, the age and grade listed is correct. We recognize that all sports have some risk of injury and hereby release JW Basketball, host sites, and all officers and coaches affiliated with these organizations from any and all liability claims for injury, illness and loss sustained by the participant while playing, practicing, traveling to and from incurred during this event. We (as participants and guardians) listed above in this form assume all risks and absolve, indemnify and hold harmless of any and all liability or damage, injury, or expense of any kind arising out of or connected with this event.

I also confirm that the information on this form is true and correct and that no participant under my custody is eligible to participate without my written consent and signature as the legal parent and/or guardian.

Parent/Legal Guardian(s): _______________________Date: _________

Type of Insurance: ___________________________________

Group Number: ____________________________________

Doctor’s Name: ____________________Doctor’s Phone:_________________