2012 Summer League June 1st July Games are Saturdays 3:30pm -8:30pm (TBA on teams (Schedules TBA)

) AGES: 16-25 First Deadline for Sign-ups is May 14th - $ Last Deadline for Sign-ups is May 21st - $

Name____________________________________________________ Age___________ Height: Shirt Size: DOB______________ _______

Address____________________________________________

City _______________________________ State ___________ Zip ___________________ *Parent/Legal Guardians Name _________________________________________________________________________ Home Phone _________________ Cell Phone ____________________ E-mail Address: ____________________________________________________________________________

IN CASE OF EMERGENCY Contact # 1 Name_________________________ Address_______________________ Phone #_______________________ Contact #2 Name________________________ Address________ ______________

Phone#_________________________

Parental Waiver and Consent Form

As the parent or legal guardian of the child named above, I hereby give my full consent and approval for my child to participate as a team member in Miami County Sports programs. I understand that there are certain risks of injury inherent in the practice and play of this sport(s), as well as in traveling and other related activities incidental to my child s participation, and I am willing to assume these risks on behalf of my child. I hereby certify that my child is fully capable of participating to the designated sport(s) and that my child is healthy and have no physical or mental disabilities that would restrict full participation in these activities, except as listed below. In addition to giving my full consent for my childs participation, I do hereby waive, release and hold harmless the organization named above, its officers, coaches, sponsors, supervisors and representatives for any injury that may be suffered by my child in the normal course of participation in the designated sport and the activities incidental thereto, whether the result of negligence or any other cause. I represent that I am a parent/legal guardian of the child named above, and I agree that the terms of this release are binding on the child and me. I also understand Miami County Basketball retains the right to use for publicity and advertising, photographs and video taken of the participants. If you have any questions, please email us at miamicountybasketball@gmail.com or contact Stephen Martin at 913-991-3954

Player Signature:

DATE:

*Parent/Guardian Signature: *(If player is under 18)

DATE:

Mail form and payment to the following address: Miami County Basketball 24083 Hospital Dr Paola, KS 66071