DIXIE COMMUNITY BASKETBALL LEAGUE

CHILDS NAME__________________________________________________________________ DOB______________________ AGE________ GRADE________ SEX M F SHIRT SIZE YS YM YL AS AM AL AXL

PARENT OR GUARDIAN_____________________________________________________________________________________ ADDRESS________________________________________________________________________________________________ HOME PHONE______________________WORK PHONE_______________________CELL PHONE_________________________

RELEASE, WAIVER, AND INDEMNIFICATION

We the parents/guardian of the above named child give our permission and approval for his/her participation in any and all activities during the season. We assume all liabilities, risks, injuries and hazards incidental to their participation in the said activity. We represent full and lawful authority to execute this release, waiver and indemnification, binding myself to the agreement. We acknowledge the program and activities may involve physical contact or conditions in which an injury may occur. We waive and release Dixie Community Basketball League and its officials, employees, sponsors, co-sponsoring organization and participating from and claims , demands, liability, cost, suits and charges of compensation for loss or injury of any kind arising from participation to presence at said activity. We acknowledge Dixie Community Basketball League will not require liability insurance coverage as a condition precedent to my childs participation in the activity, whether due to my negligence or others. I acknowledge the Dixie Community Basketball League would not offer access to the activity because of unacceptable exposure to liability claims or the expense of providing a program that is a risk free. I have read and understood this release, waiver and indemnification and it freely and knowingly intending that it shall be fully operative and effective in all respects it waives legal rights to which I may otherwise be entitled if I am hurt or suffer loss during participation in the activity.

SIGNATURE_____________________________________________________________ DATE___________________ IN EVENT OF AN EMERGENCY

In the event of a serious injury, the Dixie Community Basketball League will make every effort to contact the parent/guardian of the child. However, there are times when the best efforts are to no avail and in that case the Dixie Community Basketball League will designate a responsible person to seek medical treatment. This could include but in not limited to calling 911 for emergency help or transporting them to their medical doctor. By signing on the following line, you as a parent/guardian dive the Dixie Community Basketball League permission to seek and secure medical care of your child. The sponsoring organizations do not carry any type of insurance and all medical bills will be the responsibility of the parent/guardian.

SIGNATURE_____________________________________________________________ DATE____________________ MEDICAL INFORMATION

The following information pertains to any special medical needs and/ or information critical to your childs well-being. Please use this space to note allergies, asthma condition, food problems or emotional needs beyond normal ______________________________________________________________________________________________________________________

EMERGENCY CONTACTS IN THE EVENT PARENT/GUARDIAN CANNOT BE REACHED NAME___________________________________________ NAME__________________________________________ PHONE__________________________________________ PHONE_________________________________________ REGISTRATION COST:
$25.00 PER CHILD; $20.00 PER ADDITIONAL CHILD IN FAMILY

MAKE CHECKS PAYABLE TO DIXIE COMMUNITY BASKETBALL LEAGUE OPEN REGISTRATION TUESDAY, OCTOBER 22
nd

and 29
st

th

- 3pm-7pm @ DIXIE COMMUNITY CENTER

REGISTRATION DEADLINE IS FRIDAY, NOVEMBER 1

ALSO FORMS CAN BE MAILED TO 154 RYAN RD, HATTIESBURG, MS 39401 QUESTIONS TEXT 601-606-1178

AGE GROUPS: BOYS 6-8 9-11 12-14

GIRLS 6-8 9-11 12-14

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