Two Rivers Buddy Ball

 Two Rivers Buddy Ball Basketball & Cheerleading

I AM SIGNING MY CHILD UP FOR: Basketball_______ Cheerleading______

Player Registration, Information, and Releases

PARTICIPANT INFORMATION: Please Complete In Details:
Name:__________________________ Nickname:__________________________
Birthday:______________________ Age_________ Male:______ Female:_______
Address:_________________________________________________________
City/State:____________________________________ Zip:____________________
Home Phone:___________________________ Email:____________________________
Primary Medical Condition:_________________________________________________
Secondary Medical Conditions, medical restrictions or considerations we should know about? (Spinal fusions, rods, Shunts,other):_____________________________________
________________________________________________________________________
Is this participant subject to seizures: YES____________ NO____________
Does player have any Allergies: ____________________________________________
Mobility: Wheelchair______ Walker________ Crutches______ Ambulatory______
Other_______
Sensory Impairments: Visual/Blind_______ Hearing/Deaf_______ Other
Communication: Verbal_____ Nonverbal______ Sign Language________
Assistance needed to participate: Full_____ Partial______ None_____

Medical Insurance; Insurance Company Name:__________________________________
Phone:______________________ Policy #____________________________________
Are you covered for accidents: YES________ NO_________

PARENT/GUARDIAN INFORMATION: If you are self guardian please write in SELF only.
Mother’s Name:_______________________ Father’s Name:______________________
Address:___________________________ Address:____________________________
Phone:_____________________________ Phone:____________________________
Cell Phone:_________________________ Cell Phone:________________________
Email:_____________________________ Email:___________________________

EMERGENCY CONTACT, other than Parent:
Name:__________________________________________________________________
Address:________________________________________________________________
Phone:________________________________Cell Phone_________________________
Email:__________________________________________________________________

UNIFORM INFORMATION:
Please make sure you are accurate on your size choices, once ordered they are not returnable. You will be responsible for the cost to purchase a new team uniform if you have checked the wrong size.
PUT A CHECK MARK NEXT TO YOUR CHOICES.
Uniform Shirts;
Youth Sizes: X small (2-4)____ Small (6-8)____ Med (10-12)____ Large (14-16)____
Adult Sizes: Small___ Med___ Large___ XL___ 2XL___ 3XL___ 4XL___ 5XL___

MEDIA RELEASE: Please check appropriate areas for release
I hereby certify that I, Self/Parent/Guardian ____________________________________
Consent that any film, photographs, video, sound recordings made in conjunction with the Buddy Ball program may be used for the purpose of illustration, publication, websites or broadcast in connection with the work and promotion of the Two Rivers Buddy Ball organization.
I have read the foregoing, release, and authorization before affixing my signature below and agree that I fully understand the consents.
____ NO PUBLICITY ____NAME & PHOTO ____ PHOTO ONLY

Participants name: (If minor):________________________________________________
_______________________________________Signature of Self/Parent/Legal Guardian

RELEASE: This is required to play for Buddy Ball

I parent/guardian of above named give permission to participate in the Two Rivers Buddy Ball program. I understand that the activity my child or self are participating in, is a potentially hazardous activity. I assume all risks associated with the participation of this activity. I do hereby waive, release, absolve, indemnify and agree to hold exempt Two Rivers Buddy Ball, the Board of Directors, organizers, sponsors, participants, and all persons coaching, training, volunteering or managing above participant. For any claim arising out of physical and psychological injury or loss of personal property while participating in this activity sponsored by Two Rivers Buddy Ball or the Buddy Ball organization.
Further, I authorize organization officials to obtain medical care from any licensed medical authority should above named become ill or injured while participating in activities.
I also agree to allow the Two Rivers Buddy Ball organization check and document the State Criminal Registries to ensure safety of the program.

Date:_______________________________ Signature:___________________________

Contact:
Two Rivers Buddy Ball
c/o Billy Shain- President for Buddy Ball
3531 Lewis Lane Owensboro, KY 42301
(270)315-9925 or email bshain@oolwireless.net