Allendale Youth Basketball
*Please register separately for boys and girls.*
Parent Information
First Name *
Your answer
Last Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Email *
Your answer
First Child's Information
First Name *
Your answer
Last Name *
Your answer
Age *
Your answer
Grade *
Your answer
Shirt Size *
Second Child's Information
First Name
Your answer
Last Name
Your answer
Age
Your answer
Grade
Your answer
Shirt Size
3rd Child's Information
First Name
Your answer
Last Name
Your answer
Age
Your answer
Grade
Your answer
Shirt Size
Person Other Than Parent To Be Notified In Emergency Situation When Parent Is Not Available
First Name *
Your answer
Last Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Relationship *
Your answer
Names of Person Other Than Parent To Whom Child May Be Released
Your answer
I hereby give permission to Allendale Public School Licensed by the Department of Social Services to secure emergency medical and/or surgical treatment for the named minor child while in care. *
Non-emergency medical treatment or elective surgery is not included in this authorization.
Parent's First Name *
Your answer
Parent's Last Name *
Your answer
Today's Date *
MM
/
DD
/
YYYY
Name of child's physician or health clinic *
Your answer
Phone Number *
Your answer
City *
Your answer
Zip Code *
Your answer
Hospital Preferred for Emergency Treatment *
Your answer
Health Insurance Policy Number *
Your answer
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