UPWARD BASKETBALL AND For a larger print version of these terms and conditions please visit CHEERLEADING REGISTRATION FORM www.upward.org/largerfont HOW DO I SIGN UP? 19/20 PLEASE READ CAREFULLY AND SIGN BELOW TO INDICATE YOUR AGREEMENT. PARTICIPANT CONTACT INFO: II AM REGIISTERIING MY CHIILD FOR:: BASKETBALL CHEERLEADIING NOTE: THIS FORM INCLUDES A RELEASE OF LIABILITY. BRING OR MAIL REGISTRATION FORM AND FEE TO: Pleas e review and complete the s ections below and s ign in the s pace provided to indicate your agreement with all s tatements made in s uch s ections . First Baptist Leeds-Leeds AL Last Name First Name MI Would you be willing to coach your child's team? AUTHORIIZATIION AND RELEASE OF LIIABIILIITY Yes No I, the parent or guardian of the above-named child, authorizes the participation of my child in the 7481 Parkway Dr. Upward Unlimited (herein being referred to as UU) athletic program (the "Program") of the above- Gender Grade (19-20 school year) Date of Birth / / named Church. My child will participate in the UU s port denoted on this brochure. Leeds, AL 35094 If yes, please print your name: Month Day Year I unders tand that this Program is a nonprofit Chris tian s ports minis try program for youth and that For both basketball and cheerleading, bring your registration form and Address my child's participation is voluntary and not es s ential to completion of requirements of any program, s chool or government agency. I unders tand that the Program is conducted by the Church fee to evaluation. Carpool Link (only same age/grade and gender) and its volunteers and s taff, including parents of other participating children. I als o unders tand City State Zip that the Church is s olely res pons ible for all as pects of the Program including s election and s upervis ion of all pers ons conducting the Program, and that UU is not res pons ible for the REGISTRATION INFORMATION: (other player must also list your child as their carpool link) Program or s electing and s upervis ing pers ons conducting the Program. I further unders tand and Home Phone ( ) Parent's Cell ( ) agree that my child's participation in athletic and other activities of the Program neces s arily The registration cost per child for basketball is $70. involves the ris k of injury and even death from various caus es , including but not limited to How many years has your child accidents , falls , s trenuous and prolonged phys ical activity, dehydration, illnes s , collis ion or The registration cost per child for cheerleading is $70. Church (If you regularly attend church, which one?) played organized Basketball? dis pute with other participants , weather related injuries , playing area and equipment defects , and negligence of coaches and referees . On behalf of my child, me, and my family, I as s ume thes e Basketball shorts and trophy are included at no additional cost. ris ks . In cons ideration of the privilege of my child's participation in the Program, and on behalf of Cheerleading mock turtlenecks and trophy are included at no Participant Information Notes (if any) my child and me as parent/guardian, I hereby releas e, dis charge, hold harmles s and indemnify, and covenant not to s ue, the Church and UU, and all of the Church's and UU's directors , officers , additional cost. If applicable, circle ONE night your child CANNOT practice. MON TUE THU FRI elders , trus tees , deacons , employees , volunteers , ins urers , agents and repres entatives , and all other pers ons as s ociated with the Program (including without limitation any other participating churches , s pons ors , parents , vendors , coaches and other game and event workers , officials , EVALUATIONS AND ORIENTATIONS: drivers , and organizations ) as to any and all claims of my child, me and other family members PARENT/GUARDIAN INFORMATION: for pers onal injuries s uffered by my child, property damage, medical expens es , and economic Everyone must attend one basketball evaluation or cheerleading los s aris ing directly or indirectly out of my child's participation in the Program, and any firs t aid, Father/Guardian Home Phone ( ) Cell Phone ( ) medical care or treatment provided to my child in the event my child is injured or becomes ill while orientation. participating in Program activities , and excepting claims that may not be releas ed under Email applicable law. This Releas e of Liability s hall be as broadly cons trued as allowed by law to include all claims and rights that the child, that I as parent/guardian, and that other family I would like to assist this league by being a: Coach Referee Team Parent members may have. I am a legally res pons ible parent or guardian of my child. If any provis ion of They will take place at the FBC Leeds Gym as follows: this Releas e of Liability is deemed invalid, the remaining provis ions s hall remain in full force and Basketball and Cheerleading K4-5th Grade Mother/Guardian Home Phone ( ) Cell Phone ( ) effect. This Releas e of Liability s hall be binding on me, my family, heirs , next of kin, legal repres entatives , beneficiaries , s ucces s ors and as s igns I hereby authorize the Church and UU to Monday, October 21, between 6:00 p.m. and 8:00 p.m. Email us e, reproduce, dis tribute, dis play, and to licens e others to us e, reproduce, dis tribute, and dis play, my child's image, and photograph, as well as any video, digital, or audio recording or Basketball and Cheerleading K4-5th Grade I would like to assist this league by being a: Coach Referee Team Parent reproduction, in connection with external and internal communications of the Church and UU for the s ole purpos e of advancing UU programs . I acknowledge and cons ent that regis tration will allow Tuesday, October 22, between 6:00 p.m. and 8:00 p.m. UU to obtain acces s to pers onal information regarding me and my child participant. I agree that Emergency Contact Daytime Phone ( ) Evening Phone ( ) UU may us e s uch pers onal information in a manner cons is tent with UU's Conditions of Us e and Basketball and Cheerleading K4-5th Grade Privacy Policy as amended from time to time. I further unders tand that the current vers ion of UU's Monday, October 28, between 6:00 p.m. and 8:00 p.m. Conditions of Us e and Privacy may be found at www.upward.org. SIZING: (COMPLETED AT EVALUATIONS/ORIENTATIONS) EVALUATIONS: ((COACHES USE ONLY)) Basketball and Cheerleading K4-5th Grade PARTIICIIPATIION AND SAFETY Basketball Jersey/Cheer Top Size (circle one): I unders tand that participation in the Program may involve s trenuous and prolonged phys ical Tuesday, October 29, between 6:00 p.m. and 8:00 p.m. activity. I agree that my child is healthy and able to participate in the Program activities . I YXS YS YM YL YXL/AS AM AL AXL A2X Lane Shooting Right-Side Shot unders tand that the Church or its repres entatives may reques t health information concerning my child and/or as k my child to undergo a medical exam. If the Church determines that my child does PROGRAM SCHEDULE: Basketball Shorts Size (circle one): have a phys ical, mental or other condition that may affect his / her ability to s afely and Left-Side Shot Defensive Slide appropriately participate in Program activities (or that may affect the ability of other children to YXS YS YM YL YXL/AS AM AL AXL A2X participate s afely), the Church may determine that my child cannot be permitted to participate. I First Practice - The week of Monday, November 18, 2019 unders tand and agree that, while the Church des ires that all children will be able to participate, First Game - Saturday, January 11, 2020 Cheer Skort Size (circle one): Right Hand Dribble Left Hand Dribble s uch decis ions may have to be made out of concern for the bes t interes ts of my child and other participants . Awards Celebration - Saturday, February 29, 2020 YXS YS YM YL YXL/AS AM AL AXL A2X Height - in inches CONSENT TO MEDIICAL TREATMENT Cheer Mock Turtleneck Size (circle one): In the event my child is injured or becomes ill in Program activities , and if I, the parent or guardian FOR MORE INFORMATION: of the above-named child, am not pres ent to make medical decis ions , I hereby authorize the YXS YS YM YL YXL/AS AM AL AXL A2X Church, its s taff, volunteers including volunteer parent participants , coaches , as s is tant coaches , and referees , s upervis ors and drivers , to arrange for and cons ent on my behalf to emergency FBC Leeds medical and dental care and treatment, including tes ts and radiological exams , and s urgery, 205-699-6141 PAYMENT: Participant Fee : $______and hos pital care and treatment, and to cons ent to medications for pain and other conditions as pres cribed by medical pers onnel attending my child. I am res pons ible for payment of any medical For basketball - [email protected] charges or expens es not covered by my ins urance or the ins urance applicable to my child (if any). My s ignature below indicates that all information provided in this form is true and accurate, For cheerleading - [email protected] OFFICE USE ONLY and that I fully agree to all s tatements made on the form, including but not limited to the Authorization and Releas e of Liability, Medical Conditions , and Cons ent to Medical Treatment. My DATE PAYMENT TYPE AMOUNT NOTE s ignature als o indicates that all legal guardians are aware and cons ens ual with the participation of the above-named child. Signature: Printed Name: Date: BRC78584 UPW69479