MENU
2012 PLAYER REGISTRATION AND MEDICAL RELEASE FORM

First Name:             MI:                         Last Name:

D.O.B:

Street Address:                                                                                     Apt. #:

City:                                         State:                                 Zip:                 Gender:

Home Phone:                           Cell Phone:                          

School:                            Grade:                  Age as of March 1, 2012:

Prior basketball experience:                               Team Names:

Height (inches):                              Weight (lbs.): 


PARENT/GUARDIAN INFORMATION          
   
Name:                                   Phone:                                Work #:


Uniform Information

Jersey SizeShorts SizeShooting ShirtSweat Suit Size


                  
Preferred Jersey Numbers 
(Please list 3 Choices)
                                               



+MEDICAL INFORMATION+

Family Doctor/HMO:                                     Phone Number:

Medical Insurance Company:                                           Policy #:

Medication Allergies:




Player’s medical history that manager/coach may need to know, or other conditions or information that may be important in the event emergency medical care is needed:





Emergency Contact :                                              Phone #:

Agreement to Participate
I, or we, grant to the Directors, Assistants, or assigned chaperons of this event to act as guardians/spokesman in granting permission for emergency treatment/hospitalization (including anesthesia) if necessary for the minor en route to or from or at the site of AAU event or hospital or other medical facility. I understand that should a health emergency arise, such parties will attempt to notify me, but that if I cannot be reached by telephone, such medical treatment as deemed necessary by competent medical personnel is authorized. I hereby authorize the AAU and/or PSPA to photograph and/or videotape me or my said child or ward and further to display, use and/or otherwise exploit my or my said child's or ward's name, face, likeness, voice, and appearance forever and throughout the world, in all media, whether now known or hereafter devised, throughout the universe in perpetuity (including, without limitation, in online webcasts, television, motion pictures, films, newspapers, and magazines) and in all forms including, without limitation, digitized images, whether for advertising, publicity, or promotional purposes or for any other purposes whatsoever, without compensation, reservation or limitation, in conjunction with my or my said child's or ward's participation in this AAU event, and understand that the AAU and/or PSPA, as applicable, retains title and exclusive and unlimited right to all internet streaming files including, without limitation, live and archived games, interviews and events broadcast to the Internet, all in conjunction with this event, and I understand and agree that I may neither pay a fee to receive individual promotional consideration from my or my said child's or ward's participation in this event, nor will I/the minor receive any payment for the possible commercial use of my or my said child's or ward's or likeness.
INSURANCE: AAU membership provides excess medical insurance for any member athlete participating in an AAU-sanctioned practice or event. If such athlete has other medical coverage, theirs will be applied first, followed by AAU insurance. I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.

NAME OF PARTICIPANT:

PARTICIPANT'S SIGNATURE:____________________

PARENTS SIGNATURE: ___________________

DATE:__________

TEAM NAME: Premier Sports Performance Academy (P.S.P.A.)

MINOR RELEASE; AND I, THE MINOR'S PARENT AND/OR LEGAL GUARDIAN, UNDERSTAND THE NATURE OF ATHLETIC ACTIVITIES AND THE MINOR'S EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED, IN GOOD HEALTH, AND IN PROPER PHYSICAL CONDITION TO PARTICIPATE IN SUCH ACTIVITY–AS IS, WITHOUT MODIFICATION OR ACCOMMODATION. I HEREBY RELEASE, FOREVER DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS EACH OF THE RELEASEES FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON THE MINOR'S ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE ACTION, INACTION AND/OR NEGLIGENCE OF THE RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS AND FURTHER AGREE THAT IF, DESPITE THIS RELEASE, I, THE MINOR, OR ANYONE ON THE MINOR'S BEHALF MAKES A CLAIM AGAINST ANY OF THE RELEASEES NAMED ABOVE, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION AND/OR ARBITRATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGES, OR COSTS ANY MAY INCUR AS THE RESULT OF ANY SUCH CLAIM.


Photograpgh Waiver

I agree to give permission to P.S.P.A to use my child’s picture and/or name on their website.




PARTICIPANT'S SIGNATURE:____________________

PARENTS SIGNATURE: ___________________

DATE:__________


Registration & Medical Waiver