Saint Joseph Chargers
Developmental Basketball Registration—Spring 2011
FAMILY INFORMATION
Custodial Parent or Guardian Name(s) Home Phone
Street Address Work Phone
City, State, Zip Cell Phone
Email Address(es) for mailing list: Registered Member of
St. Joseph
St. Elizabeth Ann Seton
St. Katharine Drexel
Non‐custodial Parent Information (include name, address, phone number) Non‐custodial Parent Email
PARTICIPANT INFORMATION & REGISTRATION FEE
Name(s) Gender Birthdate Grade School CCD Student Registration Fee
Last, First (mm/dd/yy) (must be baptized) $10 per child
$
$
$
$
(checks payable to SJAA) TOTAL REGISTRATION FEES DUE:
CHECKS PAYABLE TO: SJAA
MAIL REGISTRATION AND FEE TO:
Jennifer Brubaker • 129 Ridge Drive • Dillsburg, PA 17019
PLEASE NOTE: Participation is only guaranteed for those who submit a completed and signed registration form with
payment by April 12th. No refunds will be offered (cost covers the t-shirt).
VOLUNTEER INFORMATION
Volunteer Name: Home Phone: Cell Phone:
I am willing to be a: Hall Monitor Instructor
I have completed the Diocese Youth Clearances program and have a volunteer badge**. Yes No
** All Volunteers must have a Diocesan issued youth protection badge in order to volunteer for this program.
PLEASE BE SURE TO FILL OUT AND SIGN THE BACK OF THIS FORM
EMERGENCY / MEDICAL INFORMATION
Please note any medical condition coaches should be aware of:
INSURED NAME: INSURANCE CARRIER:
POLICY NUMBER:
HOSPITAL PREFERENCE:
EMERGENCY CONTACT (other than parent): PHONE:
RELEASE OF LIABILITY
In consideration of being allowed to participate in the Saint Joseph Athletics Program, sponsored by Saint Joseph Parish
and its Athletic Association, and any related events and activities, and intending to be legally bound, I:
1. Agree that I will instruct all minors I have registered that prior to participating they should inspect the facilities
and equipment to be used, and if they believe anything is unsafe, they should immediately advise their coaches
or supervisors of such condition(s) and refuse to participate;
2. Acknowledge and fully understand that registered minors will be engaging in activities that involve risk of injury
which might result not only from their own actions, inactions, or negligence, but the action, inaction, or
negligence of others, the rules of play, or the conditions of the premises or of any equipment used. Further, that
there may be other risks not known to us or not reasonably foreseeable at this time.
3. Assume all the foregoing risk and accept personal responsibility for the damages following such injury.
4. Release, waive, discharge and covenant not to sue Saint Joseph Parish and/or Saint Joseph Athletic Association
and the respective officers, agents, coaches, servants, and other employees/volunteers of the organizations,
and, if applicable, owners and lessors of premises used to conduct the event, all of whom are hereinafter
referred to as "releases", from any and all liability to each of the undersigned, his or her heirs and next of kin for
any and all claims, demands, losses, or damages on account of injury, caused or alleged to be caused in whole or
in part by the negligence of the releases or otherwise.
I / WE HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTAND THAT WE HAVE GIVEN UP SUBSTANTIAL
RIGHTS BY SIGNING IT AND SIGN IT VOLUNTARILY.
Parent or Guardian Signature: Printed Name and Date:
Administrative Use Only Amount Received: Date Received: Check Number / Cash
Notes / Comments: