Meadowdale Lady Mavs Feeder Basketball Registration Athlete’s Name: __________________________________________ School:____________________ Birthdate (month/date/year): ________________________ Grade entering:________________________ Mother/Guardian Name: _______________________________Home Phone:______________________ Address: ________________________________________ City: ___________________ Zip: ________ Mother/Guardian email: _______________________________Mother Cell Phone:__________________ Father/Guardian Name: _______________________________Home Phone:______________________ Address: ________________________________________ City: ___________________ Zip: ________ Father/Guardian email: _______________________________Father Cell Phone:___________________ Emergency Contact Name_____________________________ Relation:__________________________ Home Phone:______________________________________ Cell Phone_________________________ Medical Conditions we should be aware of:_________________________________________________ Medical Insurance Organization:_________________________________________________________ Other organized sports in which player participates & time of year:_______________________________ ___________________________________________________________________________________ Does player have a primary sport? If so, what? _____________________________________________ Has player been on other basketball teams before? If so, where? _______________________________ Is a parent of the player interested in helping coach?______________

MEDICAL PERMISSION In case of an emergency involving my child, the coach or other appropriate Meadowdale Feeder Basketball Program official is authorized to take all steps which may be necessary including, without limitation, the following when and if appropriate in the judgment of the official (not necessarily in the order stated when more than one step is taken): (1) call 911 or an equivalent number to summon emergency medical assistance; (2) call the child’s emergency contact as listed on this registration form; (3) if unable to reach persons identified in (2) above: (a) call or take child to a locally available physician or (b) take child to a local hospital. I hereby authorize any provider of medical assistance listed above including any physician, paramedic and any hospital to provide such medical treatment and procedures as may in his/her or its judgment be necessary. I release and hold harmless the athletic coaches, physicians, and the Meadowdale Feeder Basketball Program of any and all responsibility and liability for any injury or claim resulting from athletic participation at try-outs and/or practices prior to October 1, 2011.

_________________________________Parent Signature _____________________ Date _________________________________Parent Printed Name