Sign-Up Form

PLAYER INFORMATION:

Player's First Name

Player's Last Name

Birthdate

Gender

School

Grade Age

Last 4 digits of SS#

PARENT / GUARDIAN CONTACT

Name

Address

City Zip

Home Phone

Work Phone

Cell Phone

Other

EMERGENCY CONTACT

Name

Home Phone

Work Phone

Cell Phone

Insurance Phone

Policy #

Doctor's Name

Doctor's Phone

Child's Name
has my permission to participate in training competition, events, activities, and travel sponsored by AZ REC/ARCH. I recognize that the AZ REC/ARCH leaders are serving to the best of their ability and I approve the program leader who will be in charge of this program. I certify that the participant has full medical insurance with the comnpany lised above. I also certify to the best of my knowledge that the player name herein is physically fit to participate in the rigorous activities of the game of basketball presents.

Parent/Guardian Signature (Typing your name gives permission)

Date

Relationship to Program Participant

TO THE PROGRAM LEADER:

If during the course of my Daughter's/Son activities associated with AZ REC/ARCH, she/he should become ill or sustain an injury, I hereby authorize you to obtain emergency medical care.

Parent/Guardian Signature (Typing your name gives permission)

Date

I DO NOT authorize emergency medical/dental care for my daughter/son.

Parent/Guardian Signature (Typing your name gives permission)

Date

Submit my question/comment to the following Athletic Director:

Individual commitment to a group effort—that’s what makes a team work, a company work, society work, a civilization work.”

-Vince Lombardi