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2012 Summer League

June 1stJuly

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 ____________________

Email Address:

____________________________________________________________________________

IN CASE OF EMERGENCY

Contact # 1 Contact #2

Name_________________________ Name________________________

Address_______________________ Address________ ______________

Phone #_______________________ Phone#_________________________

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Parental Waiver and Consent Form

As the parent or legal guardian of the child named above, I hereby give my full consent andapproval for my child to participate as a team memberin Miami County Sports programs. Iunderstand 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 amwilling to assume these risks on behalf of my child. I hereby certify that my child is fully capableof participating to the designated sport(s) and that my child is healthy and have no physical ormental 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 andhold harmless the organization named above, its officers, coaches, sponsors, supervisors andrepresentatives for any injury that may be suffered by my child in the normal course ofparticipation in the designated sport and the activities incidental thereto, whether the result ofnegligence or any other cause. I represent that I am a parent/legal guardian of the child namedabove, 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 atmiamicountybasketball@gmail.comor contact

Stephen Martin at 913-991-3954

Player Signature: DATE: .

*Parent/Guardian Signature: DATE: .

*(If player is under 18)

Mail form and payment to the following address:

Miami County Basketball

24083 Hospital Dr

Paola, KS 66071

mailto:miamicountybasketball@gmail.commailto:miamicountybasketball@gmail.commailto:miamicountybasketball@gmail.commailto:miamicountybasketball@gmail.com