Upward Basketball
Kindergarten
through 6th Grade
Southern
712-276-9376
in
conjunction with:
Morningside Assembly of God
Morningside Lutheran Church
Redeemer Lutheran Church
Parents
may drop off their form and registration fee at the Southern Hills Baptist
Church anytime
between 9:00 am and 2:30pm, Monday through Thursday, or anytime in the red box
outside the front door.
Registration
Information:
The early registration cost per child for basketball is $55.
After November 7, add $10.
Basketball shorts are optional at a cost of $15.
Evaluations
and Sign-ups:
Everyone must attend one basketball evaluation.
They will take place at the Southern Hills Baptist Church as follows:
Kindergarten through 2nd Grade Boys/Girls Monday, November 10
between 6:30 pm and 8:00 pm
3rd and 4th Grade Boys/Girls Tuesday, November 11,
between 6:30 pm and 8:00 pm
5th and 6th Grade Boys/Girls Thursday, November 13, between
6:30 pm and 8:00 pm
League
Schedule:
Practices begin the week of January 5, 2009.
Picture Day - Friday, January 9, or Saturday, January 10, 2009.
First Game - Saturday, January 17, 2009.
Kindergarten leagues meets on Saturday only, for one hour, beginning Saturday,
January 17, 2009.
Awards Celebration - Sunday, March 8, 2009.
For
More Information:
Southern Hills Baptist Church (712) 276-9376 or www.shillsbaptist.com
08/09
UPWARD BASKETBALL LEAGUE
REGISTRATION FORM
Player
Information
Address
Birthday MM/DD/YYYY
City
State
Zip Code
Home
Phone
Parents Email
Church (if you regularly attend church, which one?)
Player information Notes (if any)
Player
Experience and Sizing Info:
Jersey
Size
YS YM YL Y
XL Adult
S Adult
M Adult
L Adult
XLAdult X2L
Basketball Shorts Size YS
YM YL Y
XL Adult
S Adult
M Adult
L Adult
XLAdult X2L
If applicable, check ONE night you CANNOT practice Monday
Tuesday Thursday
Friday
Have you ever played organized basketball
before?Yes
No
If so How many years?
Parents/
Guardian Information:
Father/Guardian
_____________________________________________________
Telephone (Work)
___________________________________________________
Employer
__________________________________________________________
I can do one of the following for this player's team:
Coach Assistant
Coach Referee Team
Parent
Mother/Guardian ____________________________________________________
Telephone (Work) ___________________________________________________
Employer __________________________________________________________
I can do one of the following for this player's
team:
Coach Assistant
Coach Referee Team
Parent
Emergency Contact: ______________________________________________________________
Daytime Phone: (______)__________________________________________________________
Evening Phone: (______)__________________________________________________________
EVALUATIONS:
(COACHES USE ONLY)
Lane
Shoot
_____
Slide
____
Right Side Shot _____ Right Hand Dribble ____
Left Side Shot _____ Left Hand Dribble ____
Total Score _____
Height - in inches (NOT included in total) _____
Please
Read Carefully - Release Must Be Signed
Does
this child have any disabilities, handicaps, present injuries or limitations,
allergies, hemophilia, heart condition,
history of respiratory illness or any
other significant medical condition? Yes
No
If Yes, please state
conditions: __________________________________________________
If you wish to have your family doctor contacted in case of emergency:
Doctor's Name: _______________________________________ Phone # ____________________________
AGREEMENT:
NOTE THIS FORM INCLUDES A RELEASE OF LIABILITY:
Please review and complete the sections below and sign in the
space provided to indicate your agreement with all
statements made in such
sections.
AUTHORIZATION
AND RELEASE OF LIABILITY:
I the parent or guardian of the above-named child authorize the
participation of my child in the Upward Unlimited
athletic program (the
"Program") of the above-named Church. My child will participate
in the Upward (Soccer, basketball,
cheerleading, flag football) (circle program
that applies) program.
I understand the this Program
is a nonprofit Christian sports ministry program for youth and that my child's
participation is
voluntary and not essential to completion of requirements of
any program, school or government agency. I understand that
the Program is
conducted by the Church and its volunteers and staff, including parents of other
participating children. I also
understand that the Church is solely
responsible for all aspects of the Program including selection and supervision
of all
persons conducting the Program, and that Upward Unlimited is not
responsible for the Program or selecting and supervising
persons conducting the
Program. I further understand and agree that my child's participation in
athletic and other activities
of the Program necessarily involves the risk of
injury and even death from various causes, including but not limited to
accidents,
falls, strenuous and prolonged physical activity, dehydration,
illness, collision or dispute with other participants, weather
related injuries,
playing area and equipment defects, and negligence of coaches and
referees. On behalf of my child, me, and
my family, I assume these risks.
In consideration of the
privilege of my child's participation in the Program, and on behalf of my child
and me as parent/ guardian,
I hereby release, discharge, hold harmless and
indemnify, and covenant not to sue, the Church and Upward Unlimited, and all
of
the Church's and Upward Unlimited's directors, officers, elders, trustees,
deacons, employees, volunteers, insurers, agents,
and representatives, and all
other persons associated with the Program (including without limitation any
other participating
churches, sponsors, parents, vendors, coaches and other game
and event workers, officials, drivers, and organizations) as to
any and all
claims of my child, me and other family members for personal injuries suffered
by my child, property damage,
medical expenses, and economic loss arising
directly or indirectly out of my child's participation in the Program, and any
first aid,
medical care or treatment provided to my child in the event my child
is injured or becomes ill while participating in Program
activities, and
excepting claims that may not be released under applicable law. This
Release of Liability shall be as broadly
construed as allowed by law to include
all claims and rights that the child, that I as parent/guardian, and that other
family
members may have.
I am a legally responsible parent or guardian of
my child. If any provision of this Release of Liability is deemed invalid,
the
remaining provisions shall remain in full force and effect. This
Release of Liability shall be binding on me, my family, heirs,
next of kin,
legal representatives, beneficiaries, successors and assigns. I give
permission for free use of my child's name and
picture in broadcasts. telecasts
or written accounts for any participation in an Upward Unlimited sponsored
event.
MEDICAL CONDITIONS:
I understand that participation in the Program may involve strenuous and
prolonged physical activity. I agree that my child is
healthy and able to
participate in the Program activities.
I Understand that the Church or
its representatives may request health information concerning my child and/or as
my child to
undergo a medical exam. If the Church determines that my child
does have a physical or mental condition that may affect his/her
ability to
safely and appropriately participate in Program activities, the Church may
determine that my child cannot be permitted
to participate. I understand
and agree that, while the Church desires that all children will be able to
participate, such decisions
may have to be made out of concern for the best
interests of my child and other participants.
CONSENT TO MEDICAL TREATMENT
In the event my child is injured or becomes ill in Program activities, and if I,
the parent or guardian of the above-named child,
am not present to make medical
decisions, I hereby authorize the Church, its staff, volunteers including
volunteer parent participants,
coaches, assistant coaches, and referees,
supervisors and drivers, to arrange for and consent on my behalf to emergency
medical
and dental care and treatment, including tests and radiological exams,
and surgery, and hospital care and treatment, and to consent
to medications for
pain and other conditions as prescribed by medical personnel attending my
child. I am responsible for payment
of any medical charges or expenses not
covered by my insurance or the insurance applicable to my child (if any).
My signature below indicates
that all information provided in the form is true and accurate, and that I fully
agree to all statements
made on the form, including but not limited to the
Authorization and Release of Liability, Medical Conditions, and Consent to
Medical Treatment. Each responsible parent/guardian should sign.
Signature: _______________________________________________________________________
Printed Name:
___________________________________________________Date:_________________________________
Signature: __________________________________________ _____________________________
Printed Name:
___________________________________________________Date:_________________________________
If only one parent/guardian signs this form, the following must also be signed:
I affirm that this form was
signed by only one parent/guardian because (1) I am the sole parent/guardian
responsible for the care
and custody of the child due to death or incapacity of
the other parent/guardian or court order, or (2) I have made a good faith
effort
to obtain the signature from the other parent/guardian but have not been able to
do so due to causes beyond my control,
and I am not aware of any reason that the
other parent/guardian objects to the child's participation in the Program.
Signature: __________________________________________ _____________________________
Printed Name:
___________________________________________________Date:________________________________
PAYMENT:
Player Fee: $_____ + Shorts: $____+Late Fee: $______ =
Total: $_______
Office Use Only Paid ___________ Amount _________ Payment Type __________