One (1) Form Per Participant
Please note, we only accept checks.
Participant's Name __________________________________________________________________________________________
Current Grade _______ SS# _______________________ Date of Birth ______ /______ /______ Age __________ Sex ________
Address ________________________________________________City ____________________State ________Zip ___________
Evening Phone ____________________________________ Day Phone ______________________________________
Parent/Guardian ______________________________ Emergency Contact ____________________________________________
Contact Phone ______________________________________________
| Participant(s) Information
|
Emergency Treatment Release: In the event I can not be contacted to make arrangements for emergency medical treatment. I authorize the person in charge to seek and obtain medical treatment for my child. I also authorize transportation to the nearest medical facility in the event it should become necessary.
Liability Waiver: I certify that I understand any dangers inherent to my participation in this activity or activities and further state that I am physically sound enough to participate. I hereby relieve Greenville Magic Basketball Club, its members, agents and coaches of all liability that occurs by my participation in all programs. Furthermore, I have read and understand the refund policy.
| ______________________________ |
______________________________ |
| Signature of Parent/Guardian and Print Name |
Date |
| Paid by: |
Check Number |
Cash |
Date Pd. |
