5 Star Basketball Academy / Brentwood Leopards PLAYER REGISTRATION **

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** I understand that anyone handling this information has a legal duty to treat such information confidentially, the information shared will be used only by the staff at 5 Star Basketball Academy / Brentwood Leopards
• Any personal information will be stored securely in electronic form

PLAYER NAME *

PLAYER ADDRESS *

DATE OF BIRTH *

YYYY

PLAYER SCHOOL YEAR *

PARENT/GUARDIAN NAME *

PARENT/GUARDIAN EMAIL *

PARENT/GUARDIAN PHONE NUMBER *

Does your child have or has he/she ever experienced any of the following? (Please tick response) *

YES

1. High or Low Blood Pressure

2. Elevated blood cholesterol or Diabetes

3. Chest pains brought on by physical exertion

4. Childhood epilepsy

5. Dizziness or fainting

6. Any bone, joint or muscular problems with arthritis

7. Asthma or respiratory Problems

8. Any sustained injuries or illness

9. Any allergies

10. Any other medical conditions not mentioned above

IF ANSWERED YES TO ANY OF THE HEALTH QUESTIONS PLEASE GIVE FULL DETAILS HERE

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