Registration Form - DUBS program 1

THE DUBS PROGRAM

Dedication | Unity | Basketball | Sisterhood

A ONE OF A KIND GIRLS BASKETBALL & SELF DEVELOPMENT

PROGRAM

thedubsprogram@outlook.com
Important Information

· Eligibility: Elementary age

· Dates: November 7th, 14th, 21st, 28th

· Schedule: Program runs from 6pm-8pm every Wednesday for 4 weeks

· Location: Holy Cross School, 3615 Morning Star Dr, Mississauga

· Registration Fee: one time introductory fee of $60*

*payable via email transfer
Athlete Information
Player Name*

First NameLast Name
Player Age
T-shirt Size

SmallMediumLargeExrta Large
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
Cell Phone

Area CodePhone Number
E-mail*
Emergency Contact & Health Information
Emergency Contact Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Does the athlete have any allergies, chronic illness, or medical conditions that would limit high level activtiy?*

YesNo
Please describe*
Informed Consent & Acknowledgment

I hereby give my approval for my child's participation in any and all activities prepared by The DUBS Program.

I authorize that the program lead(s) act on my behalf according to their best judgement in any emergency requiring medical attention. The DUBS Program and its employees shall not be liable, either directly or indirectly, for any claims, or any damages, costs, and expenses, including but not limited to personal injury, property damage or lost or stolen property.

In case of injury to said child, I hereby waive all claims against The DUBS Program including coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death. I hereby waive, release and indemnify The DUBS Program and its employees from and against any such claims.

Photographs of athletes may be taken at any time for promotional purposes.
I have read and accept the above*

YesNo
Confirmation

BY CLICKING SUBMIT FORM BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Should be Empty:

THE DUBS PROGRAM

Informed Consent & Acknowledgment