Up and Coming Middle School Showcase Registration Form

Up and Coming Middle School Showcase - Registration Form

(Class of 2024, 2025 and 2026)

oneteamonedream.org

Athlete Information

Player Name *

First Name Last Name

Date of Birth *

Date Date Picker Icon

Grade *

School *

Guardian / Parents Names *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone *

Area Code Phone Number

Cell Phone

Area Code Phone Number

E-mail *

Basketball skill level *

	1	2	3	4	5

1 is Beginner, 5 is Advanced

Emergency Contact & Health Insurance Information

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number *

Area Code Phone Number

Do you have health insurance ?

Yes No, 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? *

Yes No

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
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone 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 *

Yes No

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.