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North Iowa Youth Basketball Registration Form
Complete one form per child - any questions email: basketball.nib@gmail.com
Email *
First Name *
Last Name *
Address *
Grade *
Male/Female *
Date of Birth
MM
/
DD
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YYYY
Parent/Legal Guardian's Name *
Home Phone
Cell Phone *
Parent/Guardian willing to help coach?
Clear selection
Emergency Contact Name *
Emergency Contact Phone #'s *
Participant's Medical Conditions *
Name of Participant's Physician *
Physician's Telephone #
Waiver - I am aware of the nature of this activity and I hereby assume responsiblity for the above participant to particpate and to be photographed for publicity purposes. I will not hold North Iowa Betterment and/or its employees/board members/coaches responsible in the case of an accident or injury as a result of participation. I understand that this completed form must be done prior to participation in the program. (Please type name for signature.) *
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