Presented By Lord’s Gym Sports Center
Roseville Youth Basketball League Registration
Returning Jersey Options:
 $98 if paid in full by the week of the first game
 $118 payment plan requires $60 deposit
Please Indicate returning jersey number
New Jersey Options:
 $118 if paid in full by week of the first game
 $138 payment plan requires $60 deposit
Please Indicate size jersey needed. CHILD: S M L XL
ADULT: S M L XL
Total Registration Fee Due:
(Registration is not complete without a $60 non-refundable deposit)
Players Name
Players Home Address
Grade
F
City
Players Home or Cell Phone
Age
Date of Birth
/
State
Email Address
Primary Phone Number
 Brother / Sister
 Other Relative
Emergency Contact (Adult, other than parent or guardian)
Any specific health concerns?  Yes  No
Zip Code
/
Parent / Guardian Name
What is the relationship to Player?
School
Gender
M
 Foster Parent
Secondary Phone Number
 Friend
Primary Phone Number
Player’s Health Questions
Secondary Phone Number
If yes, what are they?
Polio Vaccination  Yes  No
Drug allergies?  Yes  No
On any regular medications?  Yes  No
Date of last Tetanus shot
Neck, back or joint pain?  Yes  No
Activity Restrictions?  Yes  No
Any surgery or broken bones in past 90 days?
 Yes  No
Is player covered by a medical insurance plan?  Yes  No
(If Yes, a doctor’s release to play may be required.)
Insurance Company
Policy#
CONSENT & INFORMATION FORM
I/We the parents/guardians of the player named above, a minor child hereby apply for his/her participation in Lord’s Gym Basketball and induce
Lord’s Gym to accept this application. I/we hereby warrant that both this child and I are familiar with the risks associated with participation in an
active sport such as basketball; furthermore, I/we warrant that this child is active, in good health, anxious to play basketball and has no condition or
defect, which would interfere with his/her participation in this activity. I/We do herby agree and consent to this child’s participation in Lord’s Gym
Basketball during the current season, and also assume all risks and hazards, which are incidental to the conduct of these activities. I/We hereby
release, absolve, indemnify and hold harmless Lord’s Gym Inc., its officers, directors, employees, volunteers and any of them, their sponsors,
organizers, supervisors, of any and all liability for damage, injury, or expense of any kind arising out of, or connected with this child’s participation
in Lord’s Gym Basketball. Participation in competitive athletics may result in serious injury; it is impossible to eliminate such occurrences from
competitive sports. Players can reduce the risk of injury by obeying safety rules, following a proper conditioning program and maintaining their
equipment properly. Even if all these requirements are met and even if the athlete is in excellent physical condition with perfect equipment, serious
accidents may still occur.
AS A CONDITION OF PARTICIPATION, BY THE ABOVE NAMED PLAYER, IN THE LORD’S GYM BASKETBALL PROGRAM:
 I/We agree that, if the above named player were to need emergency medical treatment, and neither parents nor emergency contact can be
reached, consent is hereby granted for such emergency treatment as may be considered necessary in the opinion of the attending physician
or paramedic; and I/We bear sole financial responsibility for such treatment;
 I/We release the use of photographs and other visual media representations of my/our child for promotional use by Lord’s Gym Inc;
 I/WE ACKNOWLEDGE THAT I/WE HAVE READ THIS CONSENT FORM AND KNOWINGLY, ON BEHALF OF THIS CHILD,
ASSUME ALL THE RISKS IN ANY WAY IN ASSOCIATED WITH PARTICIPATION IN THE LORD’S GYM BASKETBALL
PROGRAM.
Printed Name of Parent or Guardian
Signature of Parent or Guardian
Date
BIG THANK YOU TO OUR 2015 SPONSORS & PARTNERS
Find us all online @ Lordsgym.org