Please fill out completely- including zip code
Name 1: ______________________________________________ Date of Birth: _________________ Age: _______
Address: _______________________________________________________________________________________
City: ________________________________________________________ State: ______ Zip: __________________
Email: __________________________________________ Cell Phone: ____________________________________
Name 2: ______________________________________________ Date of Birth: _________________ Age: _______
Address: _______________________________________________________________________________________
City: ________________________________________________________ State: ______ Zip: __________________
Email: __________________________________________ Cell Phone: ____________________________________
Name 3: ______________________________________________ Date of Birth: _________________ Age: _______
Address: _______________________________________________________________________________________
City: ________________________________________________________ State: ______ Zip: __________________
Email: __________________________________________ Cell Phone: ____________________________________
Name 4: ______________________________________________ Date of Birth: _________________ Age: _______
Address: _______________________________________________________________________________________
City: ________________________________________________________ State: ______ Zip: __________________
Email: __________________________________________ Cell Phone: ____________________________________
Name 5: ______________________________________________ Date of Birth: _________________ Age: _______
Address: _______________________________________________________________________________________
City: ________________________________________________________ State: ______ Zip: __________________
Email: __________________________________________ Cell Phone: ____________________________________
Please read the following information carefully. No one will be admitted into the ASSA 3v3 Basketball League unless either a parent or legal guardian signs this form. By signing this form, you are releasing all claims for injuries that the participant may sustain.
I agree to assume full risk and to waive and release all claims I have against All star sports arena. This release also includes ASSA agents, servants and employees from any such claims resulting from injury, responsible for all personal medical insurance and that the participant’s family must cover all medical cost incurred. I also understand that every precaution is taken to protect the safety of each participant.
Name 1 signature: _______________________________________________________________ Date:___________
Name 2 signature: _______________________________________________________________ Date:___________
Name 3 signature: _______________________________________________________________ Date:___________
Name 4 signature: _______________________________________________________________ Date:___________
Name 5 signature: _______________________________________________________________ Date:___________
FOR OFFICAL USE
Amount of payment: ________________________Date: ____________Sessions Enrolled:____________________________________________
PAYMENT METHOD
¨ Cash ¨ Club Account ¨ Check #____________
¨ Credit Card # _____________________________________________________Expiration Date: __________
