Application To Play Basketball Form printable pdf download

CHESTERFIELD BASKETBALL LEAGUE

APPLICATION TO PLAY BASKETBALL

APPLICANTS NAME: ________________________________________ DATE OF BIRTH: ________________

STREET ADDRESS: _________________________________________ PHONE NUMBER: _______________

CITY AND STATE : _____________________________________________ ZIP CODE: __________________

ELEMENTARY SCHOOL BOUNDARY: ______________________ ASSOCIATION: _____________________

SCHOOL ATTENDED: ____________________________________ GRADE: ___________________________

I/We, the parents or legal guardians for the above candidate for a position on a Chesterfield Basketball League

team, hereby give My/Our approval to his/her participation in any and all league activities

I/We assume all risks and hazards incidental to such participation including transportation to and from the

activities and I/We do hereby waive, release, absolve, indemnify and agree to hold harmless the Chesterfield

Basketball League, Inc., the organizers, sponsors, supervisors, participants and person transporting My/Our

son or daughter, except to the extent and in the amount covered by accident or liability insurance.

I/We agree to return all uniforms and other equipment issued to My/Our son or daughter in as good condition

as when received except for normal wear and tear.

I/We will furnish a certified birth certificate or other proof of birth of the above named candidate at this or initial

I/We understand that My/Our son or daughter is an ineligible player if he/she is named on any roster of any

official school basketball team, whether public, private or parochial, during the current school year.

Is this candidate covered by Health Insurance? _______ YES _______ NO .

Name of insurance company: _________________________________

Parent/Guardian Signature: ____________________________________________ Date: _________________

FREE AGENT NOT REQUIRING RELEASE

The above named participant qualifies as a free agent without release from _____________________________

association to play for ______________________ association because his/her parent was a ______________

for ________________________ association the previous year of ____________________ and is a _________

__________________ for the current year.

FREE AGENT REQUIRING RELEASE

The above player is hereby released from ___________________________ association to play for

___________________________ association in the ______________________ division.

REASON FOR RELEASE: __________________________________________________________________

AUTHORIZED BY: _____________________________________ (Home Association Voting Rep or President)

APPROVED BY: ____________________________________________ Date: _____________________

League Official

PLACE

BIRTH CERTIFICATE STICKER

IN THIS SPACE

11/11/2005

Application To Play Basketball Form