JGTBA 2015 Summer Camp
Registration Form
June 22-25, 10-11:30am, JAC3-5
PLAYER INFORMATION
Player Name
Address
City
Cell Phone
Age
Grade (fall’15)
School
Zip
PARENT INFORMATION
Parent
Names
Home Phone
Cell Phone
E-Mail
Address
Residence is within the currently defined enrollment area of Jefferson High School?
YES
NO
(If no, application must be submitted to the JGTBA board for waiver approval prior to acceptance.
JGTBA reserves the right to approve/deny admittance into the association in accordance with its bylaws)
** IMPORTANT **
My player as listed above would like to participate in the following:
1. camp, $10 (grades 3-8 in fall 2015)
2. conditioning w/Tony, $50 (grades3-8)
3. both camp & conditioning, $60
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TOTAL SENT WITH REGISTRATION... $ _________
(please make checks out to JGTBA)
Parent Signature:
_______________________________________________________________________________
RETURN FORM:
MAIL: Jefferson Girls Traveling Basketball Association, P.O. Box 385225, Bloomington, MN, 55438
For more information please visit our website www.jgtba.org RELEASE AND WAIVER OF CLAIMS
The undersigned parent(s) or legal guardian(s) of
(print), a minor, recognize the inherent
risks of injury to youths participating in the Jefferson Girls Traveling Basketball Program. I/We agree on behalf of
ourselves and for the minor child, that the coaches, The Jefferson Girls Traveling Basketball Program and its officials,
schools participating in the league, referee, and any party connected with the Jefferson Girls Traveling Basketball Program
shall not be held responsible or liable for any negligence, implied or otherwise, or any manner of personal injury, property
damage or loss suffered or sustained during any workout, game, practice, or team activity during the 2015 summer
traveling basketball season. I/We further hereby agree not to sue, or bring any claims, demands, or causes of damage of
any kind whatsoever against the persons and entities listed above, arising out of, or connected with, any personal injury,
death or property damage or during any camp activity. This waiver also applies to any dental injuries incurred while
participating in traveling basketball camp. Mouth guard protection is highly recommended for all participants in the
Jefferson Girls Traveling Basketball Camp Program. It is my/our express intent and purpose to bind myself, my heirs,
executors, administrators and assigns by this RELEASE AND WAIVER OF CLAIMS.
Notwithstanding anything set forth above, this RELEASE AND WAIVER OF CLAIMS shall not apply to intentional torts
committed by those persons and parties referred to above.
I/We further certify that the player named above is in good physical condition, and has no known medical or other
problem which would prevent the player from actively participating in all activities associated with the Jefferson Girls
Traveling Basketball camp.
I/We certify that I/We have carefully read the full text of this RELEASE AND WAIVER OF CLAIMS prior to signing, and
that I/We fully understand and agree to its terms.
Parent/Guardian Name:
Parent/Guardian Signature:
Date:
Address:
City:
Home Phone Number:
Work Phone Number:
Other Number
Players Birth date:
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Comments, conditions, illnesses, situations we should be aware of:
Zip:
MEDICAL INFORMATION AND ASSIGNMENT FORM
The undersigned, being the parent(s) and or sole legal guardians of
, a minor, do
hereby constitute and authorize my daughters team Coach, Assistant Coach or Parent Representative together with
all other medical, hospital and emergency personnel to carry out and institute all treatment and diagnosis in situations
where it would be impractical or impossible based upon the circumstances, to obtain additional timely consent.
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Date
Parent/Guardian
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Health Insurance Company
Policy Number/Contract Number
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Players Physician
Players Dentist
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Physician Phone Number
Dentist Phone Number
Please list any medication taken on a regular basis, including dosage and reason for medication. (Include allergy
shots and dates given)
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Please list any allergy and players reaction
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Does your player wear contacts?
YES
NO
Does your player wear glasses?
YES
NO