Kingdom Basketball Registration

Child/Children Information

Child 1 First Name

Last Name

Date of Birth

Child 2 First Name

Child 3 First Name

Last Name

Child 4 First Name

Last Name

Date of Birth

Parent/Guardian Information

Parent/ Guardian First Name

Phone

Last Name

Address

Emergency Contact

First Name

Last Name

Phone

Relationship

Does the athlete have any allergies, chronic illness, prescribed inhaler or medical conditions? If yes, please describe

I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connected therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments, or impairments which may affect my ability to participate in this program. In case of injury to said child, I hereby waive all claims against, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct training. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

I will like to request more information for low income reduced rates

I declare that the info I’ve provided is accurate & complete

BY ACKNOWLEDGING AND INITIALING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Initials

Upon submitting you will receive an email with payment information.