BCWBRC / TJMS Mid-Maryland Basketball Program

2012-2013 Registration Form

Return to Main Menu

Welcome to Basketball Coaches without Boundaries who is the parent organization for TJMS Basketball Program. Please print clearly and sign the form.

First Name:	Last Name	Middle Name:
Address:	City / State / Zip	Birth Date
Email:

Parent, Guardian and Emergency Contact Information:

Print name of guardian/father or mother ________________________ phone #

Print name of emergency contact ______________________________ phone # ________________

CONSENT FOR PARTICIPATION AND RELEASE OF LIABILITY: (Please Read and Sign)

I / We, the undersigned parents and/or legal guardian of ____________________________ , the named child

registered for a roster position on the TJMS Mid Maryland Basketball Team of Frederick, Maryland do hereby acknowledge and recognize the following:

1. Give our approval to participate in any and all club activities for the 2012-2013 season.

2. I/We consent to my/our child's participation in the basketball club with full knowledge of all risks and possible medical injuries which could occur from playing in the club and assume all risks and hazards incidental to such participation, including but not limited to; transportation to and from activities and I/We hereby waive, release, absolve, indemnify and agree to hold harmless the local club, the chartering organization, the organizers, sponsors, participants and persons transporting my/our child to and from the activities for any claim arising out of injury to my/our child, whether the results of negligence or from any other cause, expect to the extent in the amount covered by accident and liability insurance.

3. I/We understand that the insurance carried by the club is secondary to any primary insurance and subject to coverage within the scope of the insurance carrier.

4. I/We hereby acknowledge that my/our child is in excellent physical health and that I/We know of no reason whatsoever that my/our child's physical condition would prevent him/her from participating in all activities associated with the club.

5. I/We agree to return, upon request, the uniform and other equipment issued to my/our child in as good as condition as when issued except for normal wear and tear.

6. I/We have furnished a certified birth certificated for my/our child to the club officials.

7. I/We authorize the TJMS Program Coaches and staff the ability to make medical decisions in emergency situations requiring immediate action in the event I am not present.

8. I/We authorize the use of our child’s picture to be used on our website or the Mid Maryland website.

Print Guardian Name:

Guardian Signature:

Insurance Carrier/Policy Number: Date:

This form is required to be returned with a $75 Non-Refundable Deposit at the 1^st Day of Practice. $200 Balance is due

No later than November 2^nd.