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BRC64501

For a larger print version of these terms and co

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PLEASE READ CAREFULLY AND SIGN BELOW TO INOTE: THIS FORM INCLUDES A RELEASEOF LIABIPlease reviewand complete the sectionsbelow andwith all statements made in such sections.AUTHORIZATION AND RELEASE OF LIABILITY

I, the parent or guardian of the above-named child,Unlimited (herei n being referred to asUU) athleti c prchild will participate in the UU sport denoted on thisbrI understand that thisProgram is a nonprofit Christiaparticipation is voluntary and not essential to cogovernment agency. I understand that the Program including parentsof other participating children. I alsaspectso f the Program including selection and supervis not responsible for the Program or selecting andunderstand and agree that my child'sparticipation ininvolvesthe risk of inj uryand even death from variostrenuous and prolonged physical activity, dehydratiweatherrelated injuries, playing area and equipmebehalf of my child, me, and my family, I assume theparticipation in the Program, and on behalf of mdischarge, hold harmless and indemnif y, and covenanand UU's directors, officers, elders, trustees, dearepresentatives, and all other personsassociated wiparticipati ng churches, sponsors, parents, vendors, drivers, and organizations) as to anyand all claimsinjuries suffered by my child, property damage, meindirectlyout of my child'sparticipation in the Programmychild in the event mychild is injured orbecomesilclaimsthat maynot be released underapplicable lawas allowed bylaw to include all claimsand rights tfamilymembersmay have. I am a legallyresponsiblRelease of Liabilityis deemed invalid, the remaininRelease of Liability shall be binding on me, my famisuccessors and assigns I hereby authorize the Churclicense others to use, reproduce, distribute, and disvideo, digital, or audio recording orreproduction, in cthe Church and UU forth e sole purpose of advancing Uwill allow Upward to obtain accessto personal informaUpward may use such personal information in a manamended from time to time. I further understand that mayb e found at www.upward.orgPARTICIPATION AND SAFETY

I understand that participation in the Program mayi n

that mychild is healthyand able to participate in threpresentativesmayrequest health information conceexam. If the Church determinesthat my child doeshahis/herabilityto safely and appropriatelyparticipate inchildren to participate safely), the Church may deterunderstand and agree that, while the Church desiresthmayhave to be made out of concern forthe best interCONSENT TO MEDICAL TREATMENT

In the event mychild is injured or becomes ill in Prabove-named child, am not present to make medvolunteers including volunteer parent participants, codrivers, to arrange for and consent on my behalf tincludin g tests and radiolog ical exams, and surgermedicationsfor pain and other conditionsas presresponsible for payment of any medical chargesor eapplicable to mychild (if any). Mysignature belowinand accurate, and that I fully agree to all statemen

Authorization and Release of Liability, Medical Cresponsible parent/guardian should sign.

I affirm that this form wassigned by only one pareresponsible for the care and custodyof the child duecourt order, or (2) I have made a good faith effort to ohave not been able to do so due to causesbeyond mparent/guardian objectsto the child'sparticipation in t

REGISTER ONLINE, MAIL OR BRING INFORMATION TO:

Pinelake Church-Brandon MS6071 Highway 25

Brandon, MS 39047-9317

Register Online at http://registration.upward.org/UPW53702Registration forms may be dropped off Monday - Thursday

between 8:00 a.m. - 5:00 p.m. or on Fridays between

8:00 a.m. - 4:00 p.m. Registration Forms may be mailed to:

Attn: Upward, 6071 Hwy. 25, Brandon, MS 39047REGISTRATION INFORMATION:

The registration cost per child for basketball is $80.The registration cost per child for cheerleading is $80.Deadline for registration is October 29.Basketball shorts are optional at a cost of $15.Cheerleading turtleneck is optional at a cost of $15.Register early.

EVALUATIONS AND ORIENTATIONS:

Everyone must attend one basketball evaluation orcheerleading orientation.

They will take place at the NWR Middle School Gym as follows:K5 & 1st Grade Girls & BoysThursday, October 24, between 6:00 p.m. and 8:00 p.m.2nd & 3rd Grade Girls & BoysMonday, October 28, between 6:00 p.m. and 8:00 p.m.4th & 5th Grade Girls & BoysTuesday, October 29, between 6:00 p.m. and 8:00 p.m.

LEAGUE SCHEDULE:

First Practice - Monday, December 2, 2013First Game - Saturday, January 11, 2014Awards Celebration - To Be Determined

FOR MORE INFORMATION:

Pinelake Children's Staff601-829-4539 or upward@pinelake.org

HOW DO I SIGN UP? 13/14UPWARD BASKETBALL ANDCHEERLEADING REGISTRATION FORM

Signature:

PrintedName:

Signature:

PrintedName:

Signature:

PrintedName:

Basketball Jersey/Cheer Top Size (circle one):

YXS YS YM YL YXL/AS AM AL AXL A2X

Basketball Shorts Size (opt ional circle one):

YXS YS YM YL YXL/AS AM AL AXL A2X

Cheer Skort Size (circle one):

YXS YS YM YL YXL/AS AM AL AXL A2X

Cheer Mock Turtleneck Size (optional circle one):

YXS YS YM YL YXL/AS AM AL AXL A2X

PARTICIPANT CONTACT INFO: I AM REGISTERING MY CHILD FOR: BASKETBALL CHEERLEADING

Last Name First Name MI

Address

Gen de r G ra de ( 13-14 scho ol y ea r)

Date of Birth / /

Month Day Year

City State Zip

Home Phone ( ) Parent's Cell ( )

Father/Guardian Email

Yes

Would you be willing to coach your child's team?

No

If yes, please print your name:

Mother/Guardian Email

Church (If you regularly attend church, which one?)

Carpool Link (only same age/grade and gender)

(other player must also list your childas their carpoollink)

Participant Information Notes (if any)How many years has your childplayed organized Basketball?

If applicable, circle ONEnight your child CANNOT practice. MON TUE THU FRI

PARENT/GUARDIAN INFORMATION:

Father/Guardian Work Phone ( )

I would like to assist this league by being a: Coach Referee Team Parent

Mother/Guardian Work Phone ( )

I would like to assist this league by being a: Coach Referee Team Parent

Emergency Contact Daytime Phone ( ) Evening Phone ( )

SIZING: (COMPLETED AT EVALUATIONS/ORIENTATIONS) EVALUATIONS: (COACHES USE ONLY)

Lane Shooting Defensive Slide

Right-Side Shot Right Hand Dribble

Left-Side Shot Left Hand Dribble

Height - in inches

PAYMENT:

Participant Fee : $______ ____ + S horts : $______ ____ + Turtlenecks : $______ ____ = Total : $______ ____

OFFICE USE ONLY PAID PAYMENTTYPE AMOUNT

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