PLAYER INFORMATION

Last Name: First Name:

School:

Grade: Age: SEX: MALE FEMALE

Date of Birth: Program Code: AND33169

ADDITIONAL PLAYER INFORMATION

Last Name: First Name:

School:

Grade: Age: SEX: MALE FEMALE

Date of Birth: Program Code: AND33169

AGE DIVISION SPORT

8-9 Basketball
11 under
13 under
15 under
Please list any medical conditions, allergies, or medications for the above participant that should be considered.

PARENT/GUARDIAN INFORMATION
Name:
E-mail:
Address:
Zip Code: City: State:
Mobile Phone: Home Phone: Alternative Phone:
COMMUNICATION
Can we send you updates by text? Yes No Can we send you email updates? Yes No
EMERGENCY CONTACTS
NAME HOME PHONE MOBILE PHONE

I hereby certify that my child is of normal health and capable of full participation in the Youth Inc of Florida. Recognizing that the Youth Inc of
Florida will do its best to ensure a safe experience, I understand that there are risks and hazards inherent both from my child’s participation in the
program and from transportation to and from the program; I agree to assume these risks. I hereby release the Youth Inc of Florida, its
employees, volunteers, and agents from any and all claims from injury, illness, death, loss, or damage, resulting from my child’s participation in
the youth programs. I hereby authorize the Youth Inc. of Florida, its coaches, staff, and volunteers to obtain medical treatment for my child in
event those emergency contacts cannot be reached. I understand that the Youth Inc of Florida does not provide any accident or health insurance
Member
for its members and participants and I further understand that it is my responsibility to provide such #
coverage. I give permission for my child’s
picture to be taken and to be used for publicity purposes. I have read and voluntarily signed this waiver and release of liability, and I agree that
no oral representations, statements, or other inducements to sign have made apart from what is written on this form.

PARENT/GUARDIAN SIGNATURE: ______________________________________________ DATE: _________________________________

Hawks Basketball Registration