Crossroads CYC

Basketball Registration

Player's First Name *

Player's Last Name *

Player's Email

Player's Cell

Birthdate *

Age on September 1st, 2011 *

Height *

Please list any allergies or medical conditions *

Father's Name *

Mother's Name *

Parent's Email *

Cell Phone *

Cell Phone

Texting on Cell - (for emergencies & last minute game or practice changes) * Yes No

Home Phone

Street Address *

City, State, Zip *

I give Crossroads my permission to use my child's photo in any Crossroads publication * Yes No

I have read the Player Agreement and agree to follow the guidelines within. * Yes No

I have read the Parent Agreement and agree to follow the guidelines within. * Yes No

In consideration of being allowed to participate in the home school sports program practices and league play with Crossroads CYC I understand and I am aware that playing sports is a potentially dangerous activity. I also understand that the activities involve a risk of injury and that I am voluntarily participating in these activities with the knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury. I hereby further declare the participants physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that would prevent participation in any of the activities or programs of Crossroads CYC. I do hereby affirm and acknowledge that it has been recommended that I have a yearly or more frequent physical examination and consultation with my physician as to the physical activity, exercise, and use of facility exercise equipment. I acknowledge that I have had either a physical examination and have been given approval by my physician to participate, or I have decided to participate in the activity without the approval of my physician and do hereby assume all responsibility for participation in the activities.

In consideration of being allowed to participate in Crossroads CYC team play and use of facilities and equipment, in addition to payment of any fees or charge, I hereby waive, release, and forever discharge Crossroads CYC and it’s officer’s, coaches, agents, employees, representatives, executors, and all others from any and all responsibilities or liability for injuries or damages resulting from participation in any activities at said facilities or transportation to and from said facilities. I hereby waive any claim I might have against Crossroads CYC, coaches, and Institution(s) providing facilities.

In case I, as parent or guardian, cannot be reached during an emergency, I do hereby give permission for my child to be treated by a licensed physician to administer whatever care necessary for their safety. Furthermore, I acknowledge that I will be responsible for any cost incurred due to sickness or injury to my child.

Parent/Guardian Digital Signature *

Crossroads

Christian Youth Center

Basketball Registration