Student Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student Phone *

(###)

###

####

Parent/Guardian #1 Name *

First Name

Last Name

Parent/Guardian #1 Phone *

(###)

###

####

Parent/Guardian #2 Name

First Name

Last Name

Parent/Guardian #2 Phone

(###)

###

####

Emergency Contact (other than parent) *

First Name

Last Name

Emergency Contact phone *

(###)

###

####

Doctor Phone *

(###)

###

####

Parent’s Approval, Medical Release, & Field Trip and Transportation Authorization *

Recognizing the possibility of physical injury associated with basketball and other athletic activities and in consideration for the Brooklyn Youth Sports Club and affiliates accepting the registrant for its programs and activities, I hereby release, discharge and/or otherwise indemnify the Brooklyn Youth Sports Club, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of the fields and facilities utilized for the Programs against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Brooklyn Youth Sports Club programs. My child has permission to participate in all BKYSC field trips and I, hereby, authorize BKYSC to transport my child to and from the field trips. Any damages or harm resulting from transportation is hereby waived. My son has received a physical examination by a physician and has been found physically capable of participating in the Brooklyn Youth Sports Club. I hereby give my consent to have an athletic trainer and/or doctor of medicine or dentistry provide my daughter with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of such assistance and/or treatment.

I agree

I do not agree