Youth Basketball Association Consent And Photo Release Form
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1West Linn-Wilsonville Youth Basketball Association
Consent and Photo Release Form
Participant Name __________________________________________________________________________
Address __________________________________________________________________________________
City
_______________________________________
State ___________
Zip ______________
School ________________________ Grade ________ Gender ________ Date of Birth ____/_____/______
Home Phone ______________________________
Participant’s Cell Phone ________________________
List any allergies, medical conditions or specific needs _____________________________________________
__________________________________________________________________________________________
Parent/Guardian (1) Name ___________________________________________________________________
Home Phone ____________________ Work Phone _____________________ Cell ____________________
Email Address _____________________________________________________________________________
Parent/Guardian (2) Name ___________________________________________________________________
Home Phone ____________________ Work Phone _____________________ Cell ____________________
Email Address _____________________________________________________________________________
Emergency Contact Name ___________________________________________________________________
Home Phone ____________________ Work Phone _____________________ Cell ____________________
Physician Name ___________________________________________________________________________
Address ______________________________________________________ Phone _____________________
Dentist Name _____________________________________________________________________________
Address ______________________________________________________ Phone _____________________
Preferred Hospital: _________________________________________________________________________
Consent and Release for Medical Treatment:
The above named participant has permission to participate in the West Linn Youth Basketball Association
(“WLYBA”) program. I acknowledge that this activity may be hazardous and I release WLYBA and its officers and
coaches from any liability for injury of the named participant. In case of emergency, WLYBA and coaches have
permission to call an ambulance or take the participant to any physician or hospital at my expense.
Parent/Guardian Signature: _____________________________________ Date_________________________
Photo Release:
I hereby grant permission to WLYBA to use any photographs taken from other team parents or a member of
WLYBA and post them on the WLYBA website. These photographs will be used to represent and promote WLYBA
practices, games or tournaments on the WLYBA web site only. I acknowledge WLYBA has the right to treat the
photograph at its discretion for formatting purposes. I also acknowledge that WLYBA may choose not to use a
photograph at this time, but may do so, at its own discretion, at a later date.
_______
YES, I have read and agree to all terms stated above and authorize WLYBA to use photographs of
my child on the WLYBA website,
_______
NO, I do not authorize WLYBA to use my child’s photograph on the WLYBA website except in a
team photo. (Example: winners of a championship).
Parent/Guardian Signature: _____________________________________ Date_________________________
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