ROC-N-ART – Recreation Outreach Center

ROCSPORTS HS Boys Basketball

2019 ROCSPORTS High School BOYS Basketball
December 9th, 2019 - February 24th, 2020 The ROC (@ Immanuel Baptist Church) $65 per person includes reversible jersey (price increase to $75 on October 21st)
Player Name*
First Last
Player Email*
Player Phone*
Player Birthday*
Date Format: MM slash DD slash YYYY
Current Grade
Years Played*
Player's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
T-Shirt Size*
Church (if you regularly attend, which one?)
Player Notes (any information we should know?)
Would you like to coach your son's team?*
If yes, please write your name here
Father/Guardian Name*
Father/Guardian Phone Number*
Mother/Guardian*
Mother/Guardian Phone Number*
Does this participant have: any disabilities, present injuries, limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant condition?*
If yes, please state the condition*
If you wish to have your family doctor contacted in case of emergency, what is his/her name?*
Family doctor phone number:*
EMERGENCY AUTHORIZATION
I, the undersigned parent or legal guardian of the participant, a minor, hereby authorize the coaches, assistant coaches or parents of the players acting in the capacity of activity supervisors/vehicle drivers, as my Agents, to consent to medical, surgical or dental examination and/or treatment. In case of emergency, I hereby **
- Authorize - Emergency
Parent/Guardian Name*
First Last
Parent/Guardian phone number*
Parent/Guardian Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Waiver of Liability and Disclaimer and Contract for Permission to Photograph
I, the parent of guardian of the above named individual, acknowledge that participation in athletic events necessarily involves risk of physical injury. I further acknowledge that the programs of the ROCSPORTS Basketball League and Immanuel Baptist are primarily administered by parents who volunteer their time rather than paid professionals. In consideration for accepting the registration of the above name individual and permitting the voluntary participation if said individuals in its program, I hereby release, discharge, and hold harmless the ROCSPORTS Basketball League, its employees, Immanuel Baptist, volunteers and other representatives from any claims arising out of relation to any physical injury that may result to said individual while participating in the ROCSPORTS Basketball League sponsored event, including any physical negligence of an official, referee or coach while performing his/her duties during any practices, games or camps. I hereby grant permission to the ROC, a department of Immanuel Baptist Church, to use my photograph for the ROCSPORTS Basketball League.*
- Authorize - Waiver of Liability
Price*
Price: $65.00
This price will cover the league fees and a reversible jersey.
Credit Card
American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name