Youth Basketball Registration Form
Complete one form per child - any questions email: basketball.nib.gmail.com
Email address
Participant's Name (First & Last)
Your answer
Address
Your answer
City
Your answer
State
Your answer
Grade
Date of Birth
Your answer
Parent/Legal Guardian's Name
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Email Address
Your answer
Are you willing to help coach?
Required
Emergency Contact Name
Your answer
Emergency Contact Phone #'s
Your answer
Participant's Allergies
Your answer
Participant's Medical Conditions
Your answer
Name of Participant's Physician
Your answer
Physician's Telephone
Your answer
WAIVER - I am aware of the nature of this activitiy and I hereby assume responsility for the above participant to participate and to be photographed for publicity puroses. I will not hold the North Iowa Betterment and/or its employees/board members responsible in the case of an accident or injury as a result of this participation. I understand that this completed form must be done prior to participation in this program. (Please type name for signature.)
Your answer
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