Players Name:    

Street:  

City: State:     Zip:

Phone: cell:       

 Age:   Grade:    Gender Male Female

Birth Date:     E-Mail   School:

Height       

Weight

Position

Total Amount 

Health Insurance Co.      Group #: Policy #:
My child is in excellent physical health and capable of participating in strenuous physical activity, and waive Backcourt Hoops of any and all responsibilities for injury or illness. I hereby authorize the director of Backcourt Hoops to act for me according to their best judgment in any emergency requiring medical attention. I understand that I am solely responsible for the payment of any such medical expenses and must provide Backcourt Hoops with proof of insurance. I also understand that my payments are non-refundable, non-transferable under any circumstances.
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