2015-2016
HOUSE LEAGUE REGISTRATION
245 King George Road, Suite 177
Brantford, ON N3R 7N7
www.briersbasketball.ca
[email protected]
Voice Mail – 519-756-8435
PLAYER’S NAME:
ADDRESS:
CITY:
DIVISION
ROOKIE (4 ½ - 7)
NOVICE (8,9)
ATOM (10,11)
BANTAM (12,13)
MIDGET (14,15)
JUVENILE (16,17)
JUNIOR (18)
PAYMENT RECEIVED
CASH
CHEQUE
POSTAL CODE:
PHONE #:
FOR CLUB USE
CELL #:
T-Shirt Size
EMAIL:
BIRTHDATE:
FEMALE:
$30 charge on all NSF cheques
MALE:
Youth
Adult
$20 administrative fee on all refunds
CASH OR CHEQUE ONLY
S
M
L
XL
I would like to volunteer
to coach my child’s team.
LIABILITY WAIVER: To: THE BRIERS BASKETBALL CLUB, its agents, employees, administrators, sponsors, coaches, convenors,
managers or assigns:
I, the undersigned, the parent or legal guardian of ________________________ (hereinafter referred to as “the player”), hereby
authorize and permit the player to participate in the activities of the Briers Basketball Club.
In giving this authorization and, in the event of any injury or loss occurring to the player at any time during the current season, I
hereby release and agree to bring no action whatsoever or assert any cause of action whatsoever against the Briers Basketball
Club, or any of its agents, employees, administrators, sponsors, coaches, convenors, managers or assigns by reason of any alleged
act of negligence, breach of contract or statutory duty or any other cause of action known to law. By signing below, I assume all
risks associated with the game of basketball.
PHOTO USE: I hereby agree that the above player’s name/photograph/image/audio recording/video recording, or other visual
reproduction may be used by Brantford Briers Basketball, The RISE Centre, and Aerial Promotions, in its promotional, publicity
and informational material.
NAME USE: I consent to the use of the player’s name for the purposes of publishing participant names, game results and statistics.
IF, IN THE SOLE DESCRETION OF OUR CONVENORS/COACHES,
YOU DISRESPECT THE SPIRIT OF FAIR PLAY YOU WILL BE ASKED TO LEAVE THE FACILITY.
I certify that I have read all the terms and conditions as noted above, and do intent to be legally bound thereby.
Dated at Brantford, Ontario, this ______ day of ______________________ 20_____.
____________________________________
Parent/Guardian Signature
Your copy of this registration form serves as a receipt for your Children’s Fitness Tax Credit
CHILDREN’S FITNESS TAX CREDIT
RECEIVED FROM _____________________________________
FOR BRIERS BASKETBALL PROGRAM.
FOR CLUB USE ONLY
Rev-Jun 3, 2015
THE AMOUNT OF $ ___________