Spring League

County Clippers Basketball Spring League Registration

Health Waiver & Release Form

$120 - Six Sessions E-transfer treasurer@countyclippers.ca

Grades 1-6 | Wednesday at either 5:30 or 6:30

Session Dates: April 29, May 6/13/20/27 June 3 Email info@countyclippers.ca with any questions.

Player First name

Player Last name

Gender

Male

Female

Height

Weight

Birthday

Year

Month

Day

Which age group are you registering for

Grades 1 & 2

Grades 3 & 4

Grades 5 & 6

Parent / Gurdian First Name

Parent / Guardian Last Name

Parent / Guardian Email

Address

Phone

Do you concent to recieve emails containing updates, promotions, newsletters & invitations to programs & events hosted by The County Clippers

No

Yes

Do you consent to your childs photo being used on The County Clippers social media & Website?

No

Yes

Primary Emergency Contact First & Name

Primary Emergency Contact Phone Number

Secondary Emergency Contact First & Name

Secondary Emergency Contact Phone Number

Does your athlete have any alergies, limitation, or medical condistions that you would like us to be aware of?

Has the athlete been exposed to any communicable diseases in the last three weeks

Yes

No

Should the athlete be restricted from any activity

Yes

No

If your player is covered by the Ontario Health Insurance Plan (OHIP), you acknowledge that OHIP may have limited coverage for certain health services and that you are responsible (e.g. private medical insurance) for any additional costs not covered.

Yes

Full Legal Name on OHIP Card

You understand you will be financially responsible for any medical attention your player needs during tryouts or resulting from an injury received at tryouts. You give permission for the named player to receive emergency medical or surgical treatment and

Yes

Parent / Guardian First & Last Name

I declare that the info I’ve provided is accurate and complete.

Parent / Guardian Signature

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