MEDFORD BASKETBALL BOOSTER CLUB, INC.
Registration Form / Emergency Consent
Player Name:____________________________________________________________
Grade (during basketball season):___________ Gender: M or F (circle one)
Parent's Name: ______________________________________________________________
Address: ____________________________________________________________________
Street City Zip
Telephone Number: ____________________________________________________________
E-Mail Address: ______________________________________________________________
Family Physician & Address: ______________________________________________
Family Dentist & Address: ________________________________________________
Pre-existing medical conditions: _____________________________________________
Medications currently taking: ________________________________________________
Insurance Information: Company: ______________________________________________
Policy/Group#: _________________________________________________
My child has my permission to participate in the activities of Medford Basketball
Booster Club, Inc., and I consent that Medford Basketball Booster Club, Inc.,
may, in its discretion, place basketball game or practice photographs of my child
on its website.
******************************************************************************
Emergency Consent for Treatment of Minors
As the undersigned parent/guardian of _________________________________,
whose birth date is ___________________, in the event the parent/guardian cannot
be contacted through reasonable efforts, does hereby empower and grant to the
Medford Basketball Booster Club, Inc. permission to consent to and authorize medical
and hospital care and treatment for my above named child. I hereby release and
hold harmless the physicians, hospital and other persons who act in reliance upon
this authorization from all liability in performing any and all medical and
surgical procedures which they, in their sole discretion, deem necessary.
_________________________________________________ ________________
(Parent/guardian signature) (Date)
This emergency consent for the treatment of minors needs to be completed by the
parent/guardian so that your minor child can be treated even if you are present
or out of contact at the time the emergency occurs. The above information must
be signed and returned prior to any participation.
All Players are required to pay $50.00 per year.
Amount paid $_____________________ Date Paid_________________________
MEDFORD BASKETBALL BOOSTER CLUB, INC.
RELEASE, WAIVER & INDEMNIFICATION AGREEMENT
PLEASE READ BEFORE SIGNING
The undersigned is the parent or guardian of the below-named child and is seeking
to have his or her child participate in basketball practices, games, tournaments
and other activities sponsored or arranged by the Medford Basketball Booster Club, Inc.
The undersigned acknowledges that the sport of basketball can, and often times does,
result in personal injury and property damage, given the nature of the sport.
The undersigned's child can not participate in basketball practices, games,
tournaments, and other activities sponsored or arranged by the Medford Basketball
Booster Club unless the terms of this document are agreed to, or if the president of
Medford Basketball Booster Club, Inc. agrees to modify its terms.
Please contact your own attorney for legal advice relating to the terms of this
document before signing it. If you want to discuss and negotiate the terms of this document,
please contact the president of Medford Basketball Booster Club, Inc.
THE UNDERSIGNED ASSUMES THE RISK OF ANY INJURY OR PROPERTY DAMAGE THAT
MAY OCCUR GIVEN HIS OR HER CHILD'S PARTICIPATION IN BASKETBALL PRACTICES, GAMES,
TOURNAMENTS, AND OTHER ACTIVITIES SPONSORED OR ARRANGED BY THE MEDFORD BASKETBALL
BOOSTER CLUB.
FURTHER, THE UNDERSIGNED RELEASES, DISCHARGES, AND AGREES TO INDEMNIFY AND
HOLD HARMLESS THE ORGANIZERS, OFFICERS, EMPLOYEES, AND VOLUNTEERS OF THE
MEDFORD BASKETBALL BOOSTER CLUB, INC., THE MEDFORD AREA PUBLIC SCHOOL DISTRICT,
THE HOLY ROSARY CATHOLIC SCHOOL, THEIR SUCCESSORS, INSURERS, AND ASSIGNS
FROM ANY AND ALL LIABILITY, PERSONAL INJURY, AND PROPERTY DAMAGE,
AND ANY AND ALL LOSS WHATSOEVER ARISING FROM THE NEGLIGENCE OF ANY SUCH
INDIVIDUAL OR ENTITY, AND THE UNDERSIGNED CHILD’S PARTICIPATION IN ANY ACTIVITIES
RELATED TO BASKETBALL PRACTICES, GAMES, TOURNAMENTS, AND OTHER ACTIVITIES
SPONSORED OR ARRANGED BY MEDFORD BASKETBALL BOOSTER CLUB, INC.
THIS DOCUMENT DOES NOT ATTEMPT TO RELEASE ANY PERSON OR ENTITY FOR ANY LOSS
RESULTING FROM AN INTENTIONAL TORT.
(Please Write Legibly)
Name of Child:______________________________________ Grade:_____________
Date:_________________________________________________________________________
Parent/Guardian's Printed Name:_______________________________________________
Address:______________________________________________________________________
_____________________________________________________________________________
Telephone:_________________________ Email:____________________________________
Parent/Guardian's Signature:__________________________________________________
PLEASE READ BEFORE SIGNING