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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