Player Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does the player live within Juanita High School boundaries? *

Yes

No

Parent/Guardian Name 1 *

First Name

Last Name

Parent/Guardian Phone 1 *

(###)

###

####

Parent/Guardian Name 2

First Name

Last Name

Parent/Guardian Phone 2

(###)

###

####

Physician Phone *

(###)

###

####

Consent and Liability Waiver - I/We the parents/guardians of the above named person who is trying out for a position on a Juanita Girls Basketball Club hereby give my/our approval for a duly appointed member of JBC to seek or administer emergency first aid or medical attention required for the safety or well being of my/our child while participating in any and all of the activities of the JBC program. I/we do further hereby release absolve indemnify and hold harmless the Juanita Girls Basketball Club, the organizers, sponsors, or supervisors the attending physician hospital or medical group involved in the emergency attention of your child. *

Yes

No

Date *

MM

DD

YYYY