Register for The Gate City Kings Basketball Club



First Name:

Last Name:
Age
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old

Date of Birth:

Addresss:

City:

State:

Zip:

Parent/ Legal Guardians name:

Home phone number:

Cell phone number:

Email:

School:

In case of an Emergency



Contact First Name:

Address:

Home phone number:

Cell phone number:

Work number:

Contact Second Name:

Address:

Home phone number:

Cell phone number:

work phone number:

MEDICATIONS CANNOT BE GIVEN TO ANY CHILD OR ANYONE EMPLOYED BY GATE CITY KINGS BASKETBALL TEAM



Participant's Allergies:

Participant's Medical Conditions:

Name of Participant Physician:

Physician's Telephone:

Additional Information:

WAIVER OF LIABILITY RELEASE FORM

I am aware of the nature of this activity and I hereby assume responsibility for to participate and to be photographed for publicity purposes. I will not hold the Gate City Kings Basketball team and/or its employees responsible in the case of accident or injury as a result of this participation. I understand that this completed form must ne im the possession of the Gate City Kings Basketball Team prior to participation in this program.

Parent/Legal Guardian Electronic Signature:

Date: