Player Name * First Name Last Name Date of Birth * MM DD YYYY Player School * Bartonville Grade School Hollis Grade School Limestone Walters Grade School Monroe Grade School Norwood Grade school Pleasant Hill Grade School Pleasant Valley Grade School Other Grade Level * 2nd Grade 3rd Grade 4th Grade 5th Grade Gender Male Female Player Shirt Size * YXS YS YM YL AS AM AL AXL Player Request Request are taken into consideration but not guaranteed. Parent/Guardian * First Name Last Name Parent/Guardian Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Guardian Phone Number (###) ### #### Parent Guardian Email * Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### Would you or someone you no like to coach? * Head Coach Yes Assistant Coach Yes No Name of Interested Coach First Name Last Name Phone Number of Interested Coach (###) ### #### Email of Interested Coach Waiver * CONSENT, ASSUMPTION OF RISK AND LIABILITY WAIVER I hereby consent to allow my child, _______________________________, to participate in the Limestone Jr. Basketball League (The League). I recognize and acknowledge that there are certain risks of physical injury present and I agree to assume full risk of any injuries, including death, damages, or loss, which may be sustained by my child as a result of participation in any and all activities connected with or associated with The League. I agree to waive and relinquish all claims I may have now or in the future as a result of my child’s participation in the League against The League, its officers, directors, sponsors, or coaches, and the owner of any facility where games are played including but not limited to any school districts, their boards of education, employees, volunteers or agents. I do hereby fully release and discharge The League, its officers, directors, sponsors, coaches, public schools, their boards of education, employees, volunteers and agents from any and all claims from injuries including death, damage or loss which I may have of which may accrue to me on account of my child’s participation in The League. I further agree to indemnify, hold harmless, and defend The League and its officers, directors, sponsors, coaches, public schools, their boards of education, employees, volunteers and agents from any and all claims resulting from injuries, including death, damages, and losses sustained by my child and arising out of, connected with, or in any way associated with the activities of The League. In case of accident or sickness, I consent to emergency care provided by EMT, ambulance or hospital personnel. Yes No Thank you!
