Basketball League Registration Form

One Team One Dream - Registration Form

(ages 10 - 17)

6137 Powers Ave, Jacksonville, FL 32217

oneteamonedream.org
Athlete Information
Player Name*

First NameLast Name
Guardian / Parents Names*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
E-mail*

Basketball skill level*

	1	2	3	4	5

1 is Begginer, 5 is Advanced

Interested in Volunteering while your team not playing?

CoachTeam ParentScore Book KeeperScore Clock KeeperOther
Emergency Contact & Health Insurance Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Do you have health insurance ?

YesNo, I'll pay with cash.
Insurance Carrier
Name of Policy Holder
Subscriver ID/Group Number
Card Number / Card Date
Do you have any allergies, chronic illness, or medical conditions that would limit high level activity?*

YesNo
Please describe*
Parental Permission For Emergency Treatment

In the event of illness or accident, I give my permission for emergency treatment by qualified medical personnel for my child, and I authorize the person in charge to take my child to:
I give consent for the facility to secure any and all necessary emergency medical care for my child.
Name of Physician / Emergency Medical Care Facility
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Release of Liability

Although the safety of all sport activities is the primary concern, indoor sport activities at Youth Sport Center's facilities may cause injuries and/or death. I expressly assume the risk of injury, death, and/or illness arising from any cause, and agree to waive the right to pursue any claim against the Youth Sport Center and the persons in charge.
I have read and agree to the above conditions*

YesNo
Confirmation E-mail*
Signature*

Clear
After completing this form, please click Submit Form. You will receive a confirmation email. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at oneteamonedreamallstars@gmail.com.
Should be Empty:

Release of Liability