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2017-18 ATD ATHLETICS CLUB BASKETBALL REGISTRATION FORM

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YOUTH INFORMATION

 

MEMBER NAME / (NOMBRE):______________________________________________________________AGE:_____   

 

GRADE / GRADO:______SCHOOL / ESCUELA:___________________BIRTH / FECHA DE NACIMIETO:_____/_____/______   

 

ADDRESS / DOMICILIO:_________________________________________ ____PHONE / TELEFONO #:___________________

                                STREET                                                CITY                                      ZIP

 

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PARENTS / GUARDIAN INFORMATION

 

PARENT NAME:_____________________________________________________________________________________________

(FATHER/GUARDIAN) (NOMBRE DEL PADRE)

 

HOME PHONE:_______________________CELL PHONE:_______________________WORK PHONE:_____________________

 

E-MAIL ADDRESS:______________________________________________

 

PARENT NAME:_____________________________________________________________________________________________

(MOTHER/GUARDIAN) (NOMBRE DE LA MADRE)

 

HOME PHONE / TELEFONO:_______________________CELL PHONE / TELEFONO CELULAR:_______________________

WORK PHONE:_____________________

 

E-MAIL ADDRESS / :______________________________________________

 

EMERGENCY CONTACT / CONTACTO DE EMERGENCIA

 

NAME / NOMBRE:______________________________________RELATIONSHIP / RELACION:__________________________

 

ADDRESS / DOMICILLIO:_________________________________________                ___________________________________________

STREET                                                                                CITY                                                                     ZIP

                               

PHONE /TELEFONO:_______________________CELL PHONE / TELEFONO CELULAR :_______________________

WORK PHONE:_____________________

 

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IDENTIFICATION  REQUIREMENT:  PLAYERS MUST PROVIDE     *COPY OF BIRTH CERTIFICATE*

*COPY OF MOST RECENT REPORT CARD.

                                               

Total Fees                            $________ – TOTAL PAYMENT

 

Make Payable to:      Bruce Hooks ATD Athletics (LLC)

                                    (Debit & Credit cards, Money orders, and Cash payments accepted)

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*REGISTRATION FORM*   *BIRTH CERTIFICATE*   *REGISTRATION FEE*

 

ASSUMPTION OF LIABILITY: Participation in the activity may involve risk or injury. As a parent, guardian, or participant, I am aware of these hazards and my ability to participate. I hereby agree to release, discharge and hold harmless ATD Athletics, its Board members, coaches, or other volunteers, contracted instructors, and volunteers from the liabilities which may occur while participating in the activity. I understand that participation in any recreational or sport activity involves risk. In addition, I give permission for the participant to be treated by qualified medical personnel in the event that the above named parent/guardian/emergency contact cannot be reached at the phone numbers provided. 

 

 

PARENT/GUARDIAN SIGNATURE:____________________________________________     DATE:_________________