REGISTRATION FORM
2015 - 2016 Season
SELECT DIVISION and LIST REQUESTS, IF ANY ?
WINTER HOUSE LEAGUE
[ ] GIRLS DIVISION
1-NIGHT PER WEEK basketball consisting of practices and
[ ] BOYS DIVISION
games from October to March.
•
LIST REQUESTS, IF ABSOLUTELY REQUIRED? YES [ ] NO [ ]
$185
[ ] 6:15PM PREFERRED START TIME
[ ] 7:30PM PREFERRED START TIME
[ ] NEWMARKET LOCATION [ ] AURORA LOCATION
includes 25+ weeks of basketball, complete uniform
(shirt and short), Dribble, Jump & Shoot Competitions, Year-End
Play-Off Tournament, Awards Presentation Night, and more.
:NOTE: NO GUARANTEES ON LOCATION AND START TIME
CHECK-OFF DAYS OF THE WEEK ATHLETE MAY PARTICIPATE
BASED ON OTHER COMMITMENTS. NO GUARANTEES, BUT WILL HELP
DETERMINE SCHEDULE FOR THE DIVISION.
FOR OFFICE USE
[ ] (INTRO) 6-7 YEARS
BORN: 2008,2009
[ ] MONDAY [ ] TUESDAY [ ] WEDNESDAY [ ] THURSDAY [ ] SATURDAY
[ ] (JR.NBA BASKETBALL CAMP, 12-WEEKS OF FUN DRILLS CREATED
BY NBA APPROVED BASKETBALL EXPERTS. BOYS & GIRLS AGED 5-7)
[ ] (NOVICE) 8-9 YEARS
BORN: 2006,2007
[ ] MONDAY [ ] TUESDAY [ ] WEDNESDAY [ ] THURSDAY [ ] SATURDAY
[ ] (ATOM) 10-11 YEARS
BORN: 2004,2005
[ ] MONDAY [ ] TUESDAY [ ] WEDNESDAY [ ] THURSDAY [ ] SATURDAY
[ ] THURSDAY [ ] SATURDAY
•
$125
BORN: 2002,2003
[ ] MONDAY [ ] TUESDAY [ ] WEDNESDAY [ ] SATURDAY
SESSION.1
[ ] OCTOBER-DECEMBER
[ ] (MIDGET) 14-17 YEARS
[ ] REGISTER FOR BOTH SESSIONS AND RECEIVE FREE REGISTRATION IN
WINTER HOUSE LEAGUE
[ ] (BANTAM) 12-13 YEARS
BORN: 2001,2000,1999,1998
[ ] TUESDAY [ ] SATURDAY
SESSION.2
[ ] JANUARY-MARCH
• PLEASE CIRCLE and/or CHECK-OFF PROGRAM YOU WISH TO REGISTER FOR
NAME OF ATHLETE: _____________________________________________________________
MALE: [ ]
FEMALE: [ ]
PARENT /GUARDIAN’S NAME: ______________________________________________________________________
ADDRESS: _______________________________________________________________________________________
CITY: ___________________
PHONE NO.1: (
PROVINCE: ______
) _____-_________
PHONE NO.2: (
POSTAL CODE: _____________
) _____-_________
CELL NO.: (
) _____-_________
E-MAIL: ________________________________________
E-MAIL (ALTERNATE): ____________________________________________
DATE OF BIRTH: DAY:______ MONTH:______ YEAR:______
MEDICAL CONDITIONS: _______________________________________
WE NEED YOUR HELP ! NAME: __________________________________ TEL: (
) _____-_________
[ ]COACH [ ]ASSISTANT [ ]REFEREE [ ]SCORER [ ]CONVENOR [ ]STATISTICIAN [ ]OTHER ______________________________
COACHES WILL RECEIVE IEM APPAREL, BASKETBALLS, WHISTLE, COACHES HANDBOOK and MORE…
PAYMENT OPTIONS:
[ ] MASTER CARD
[ ] CHEQUE PAYABLE TO: IEM BASKETBALL LEAGUE
[ ] VISA
[ ] AMERICAN EXPRESS
[ ] INTERAC TRANSFER ( info@iembasketball.com )
CARD NUMBER
EXPIRATION DATE (mm/yy)
CODE
NAME AS IT APPEARS ON CREDIT CARD
AUTHORIZED AMOUNT
$
RELEASE AND WAIVER
I HEREBY GIVE MY CONSENT FOR THE ABOVE MENTIONED PLAYER TO PLAY BASKETBALL UNDER THE AUSPICES OF THE IEM BASKETBALL LEAGUE. I AND THE ABOVE MENTIONED PLAYER AGREE TO ABIDE BY THE RULES
OF THE IEM BASKETBALL LEAGUE. I HEREBY ACKNOWLEDGE THAT BASKETBALL IS A PHYSICAL SPORT AND IN SO DOING I WILL NOT HOLD IEM BASKETBALL LEAGUE INC., ITS BOARD OF DIRECTORS, OFFICERS OR
REPRESENTATIVES RESPONSIBLE FOR ANY INJURIES CAUSED TO A MEMBER ARISING OUT OF HIS/HER PARTICIPATION IN THE IEM BASKETBALL LEAGUE AND AGREE TO INDEMNIFY THE IEM BASKETBALL LEAGUE FOR
ANY SUCH INJURY. I FURTHER ASSUME FULL RESPONSIBILITY FOR ANY DAMAGE CAUSED BY THE PLAYER TO ANY GYM PREMISES OR EQUIPMENT. I HEREBY GIVE MY CONSENT TO DISPLAY AND/OR LIST THE ABOVE
MENTIONED PLAYER’S NAME, THE TEAM THEY PLAY/PLAYED FOR AND STATISTICS ON THE IEM BASKETBALL WEBSITE. I ALSO GIVE MY CONSENT TO THE USE OF ANY PHOTOGRAPHS TAKEN OF THE ABOVE MENTIONED
PLAYER, WHILE PLAYING BASKETBALL, ON THE IEM BASKETBALL WEBSITE. I UNDERSTAND AND GIVE CONSENT TO HAVE THE ABOVE MENTIONED PLAYER MOVED BETWEEN TEAMS FOR BALANCING PURPOSES.
MY SIGNATURE ACKNOWLEDGES THAT I ACCEPT RESPONSIBILITY FOR THE FEES AND THAT I HAVE READ AND AGREED TO THE TERMS AND CONDITIONS LISTED ABOVE AND THE REFUND POLICY AS LISTED AT THE
BOTTOM OF THIS DOCUMENT.
I CONFIRM THAT I HAVE READ THIS RELEASE AND WAIVER BEFORE SIGNING IT AND I UNDERSTAND THAT IT IS BINDING NOT ONLY ON ME AND THE PARTICIPANT BUT ALSO ON OUR HEIRS, EXECUTORS AND ASSIGNS.
SIGNATURE: _________________________________________
ADULT PLAYER, PARENT OR GUARDIAN’S SIGNATURE
MAIL FORM (WITH PAYMENT) TO:
DATE: _________________
DAY
MONTH
YEAR
I.E.M. BASKETBALL LEAGUE INC. 913 ATAIRE ROAD, NEWMARKET, ONTARIO L3X 1L3
OR CALL 905-836-6195 FOR ADDITIONAL INFORMATION
(RETURNED CHEQUES: $25.00 SURCHARGE – REFUND CHARGE: $25.00 – NO REFUNDS AFTER SEPTEMBER 15TH)
(RETURNED CHEQUES: $25.00 SURCHARGE – REFUND CHARGE: $25.00 – NO REFUNDS AFTER SEPTEMBER 15TH)