AAU Registration Form

NOTE: A PHYSICAL EXAM SHOULD BE PERFORMED ON THE PARTICIPANT ANNUALLY.

Participant's Name

First Name

Last Name

Participant's Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Legal Guardian's Name

First Name

Last Name

Email

Phone

(###)

###

####

IN CASE OF EMERGENCY

Emergency Contact 1

First Name

Last Name

Contact 1 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact 1 - Phone

(###)

###

####

Emergency Contact 2

First Name

Last Name

Contact 2 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact 2 - Phone

(###)

###

####

MEDICAL INFORMATION

Participant's Allergies

Please list all known allergies including for food.

Participant's Medical Conditions

Please list all known medical conditions; NO MEDICATION CAN BE ADMINISTERED BY ACADEMY STAFF

Participant's Primary Physician

Physician's Phone Number

COST & WAIVER

There is no cost to tryout. If you should get an invitation to play with us, fees and other requirements will be communicated at that point.

How did you hear about us?

WAIVER OF LIABILITY AND RELEASE - I have authority to make decisions for the participant listed above. I am aware of the physical nature of basketball activities and I hereby assume responsibility for the above listed participant. I will not hold EIQ Basketball Academy and/or its employees responsible in the case of accident or injury as a result of this participation. By clicking "I agree" below, I agree to these terms.

I affirm and agree

I give EIQ Basketball Academy permission to photograph the participant listed above and use the likeness for news media and promotion.

I affirm and agree

AAU Registration Form

CONTACT

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