Panther Pipeline Registration Form

A 5 week program tailored to players wanting to get to the next level.

Cost $125

Register early as spots are limited!

Click here for program details
Athlete Information
Player Name *

First Name Last Name
Player Birth Date *

Month Day Year
Date Picker Icon
Player E-mail
Phone 1

Area Code Phone Number
Parent/Guardian Information
Guardian / Parents Name *

First Name Last Name
E-mail *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone 1 *

Area Code Phone Number
Phone 2

Area Code Phone Number

Add another parent/guardian
Guardian / Parents Name

First Name Last Name
E-mail
example@example.com

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone 1

Area Code Phone Number
Phone 2

Area Code Phone Number

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Emergency Contact & Health Information
Emergency Contact's Name *

First Name Last Name
Relationship *
Phone Number *

Area Code Phone Number
Does you have any allergies, chronic illness, or medical conditions that would limit high level activtiy? *

Yes No
Please describe *
Permissions and Consent
By signing and submitting this form I give consent that in the event of illness or accident, I give my permission for emergency treatment by qualified medical personnel for my child, and I authorize the person in charge to take my child to the nearest medical facility or the facility recommended by the responding personnel.

I give consent for the facility to secure any and all necessary emergency medical care for my child.
Name of Family Physician

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email
example@example.com
Phone Number

Area Code Phone Number
Release of Liability
Although the safety of all sport activities is the primary concern, sport activities may cause injuries and/or death. By signing and submitting this form I expressly assume the risk of injury, death, and/or illness arising from any cause, and agree to waive the right to pursue any claim against KMBA and the persons in charge.
By submitting this form I agree to the following conditions:

I agree to abide by the KMBA Code of Conduct and understand that violation of the code of conduct may result in your removal from the program. This agreement holds true for the player and other parents/guardians included on this form.

I grant permission to the Kitchener Minor Baseball Association (KMBA) to use name and limited personal information of the child indicated on this form, and also team and action photographs including their child, in print and in electronic media. Such photographs may be used by KMBA in all formats and publications including, but not limited to, newspapers, brochures and the websites of KMBA for publicity purposes. Electronic media may also include individual player stats, game and team information. No other personal information (example: address, phone number, school) will be disclosed. KMBA is committed to protecting the privacy of your personal information. The Undersigned understands that once a photograph is posted on a website, the image can be downloaded by any computer user and specifically waives his/her rights and protection pursuant to the provisions of the Personal Information Protection and Electronic Documents Act.

I allow KMBA to use contact information for future communications. KMBA gathers information solely for the purpose registration to determine eligibility of registrant to a particular level. KMBA assures all parents that it will not use the information gathered for purposes other than those required in the administration of the association. If you wish to unsubscribe from communications you will be given the opportunity to do so.
I have read and agree to the above conditions *

Yes No
Submit
Confirmation E-mail *
Let us know which email to send the confirmation to
How would you like to pay? *

Credit Card Invoice

Credit Card Info *

CAD Description

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty:

Athlete Information

Parent/Guardian Information

Emergency Contact & Health Information

Permissions and Consent

Release of Liability

By submitting this form I agree to the following conditions:

Submit