King Philip Basketball Association

Summer Basketball Registration Form

Please Print                                                                                                   Fee: $ 95.00

Name: ______________________________                               D.O.B:  _____ / _____ / _____   M  /  F

Address: ____________________________                               Telephone: (         ) _____ - ________

             ______________________________                               email:  ___________________________

                                    Grade (For 2008-2009 School Year):        5        6    

Waiver of Injury

As the parent and/or legal guardian of ____________________________________, I approve the 

participation in any and all KING PHILIP BASKETBALL ASSOCIATION activities. I recognize the

risks and hazards incidental to such participation, including transportation to and from games 

and practices. I absolve and hold harmless the KING PHILIP BASKETBALL ASSOCIATION, the 

coaches, the officers and others participating in league activities from all liability.

SIGNED: _______________________________              Date: _________ / __________ / __________

EMERGENCY TREATMENT FORM

As the parent and/or legal guardian of ______________________________________ a minor, I 

herewith authorize treatment by a qualified and licensed medical doctor in the event of a medical

emergency which in the opinion of the attending physician, may endanger his or her life, cause 

physical impairment, disfigurement or undue discomfort if delayed. This authority is granted only

after a reasonable effort has been made to contact me.

SIGNED: _______________________________               Date: _________ / __________ / _________

                          (Parent / Guardian)

PHYSICIAN: _______________________________  Telephone: (       ) _________ / __________

ADDRESS: ______________________________________________________________________

EMERGENCY CONTACT: ____________________________________

ADDRESS: _______________________________________________________________________

List all allergies and known physical impairments that we should be aware of:

PLEASE MAKE ALL CHECKS PAYABLE TO:    KING PHILIP BASKETBALL ASSOCIATION.

REGISTRATION FEE:   $95.00              DATE PAID: ___________________________

Mail to:            John Warren, 50 Martin Lane, Wrentham, Ma 02093